Provider Demographics
NPI:1619441144
Name:MASON, MICHAEL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
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 1:40 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44902-1206
Mailing Address - Country:US
Mailing Address - Phone:419-520-3853
Mailing Address - Fax:
Practice Address - Street 1:40 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44902-1206
Practice Address - Country:US
Practice Address - Phone:419-520-3853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.335725163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1790735462OtherNPI
OH2263910Medicaid