Provider Demographics
NPI:1538676234
Name:MASON, SHELBY ANN (PTA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:ANN
Last Name:MASON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 VALINDA LN
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2358
Mailing Address - Country:US
Mailing Address - Phone:208-703-6606
Mailing Address - Fax:
Practice Address - Street 1:3111 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7534
Practice Address - Country:US
Practice Address - Phone:208-529-0067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-5332225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant