Provider Demographics
NPI:1508471426
Name:MASON, TYRRIC
Entity Type:Individual
Prefix:
First Name:TYRRIC
Middle Name:
Last Name:MASON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 SEABOARD ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-2770
Mailing Address - Country:US
Mailing Address - Phone:804-586-3762
Mailing Address - Fax:
Practice Address - Street 1:633 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4132
Practice Address - Country:US
Practice Address - Phone:804-586-3762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider