Provider Demographics
NPI:1659811396
Name:MASON, TYLER JAMES
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:JAMES
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 1:5942 HUFF HILL RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45168-8961
Mailing Address - Country:US
Mailing Address - Phone:937-213-3248
Mailing Address - Fax:
Practice Address - Street 1:5942 HUFF HILL RD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:OH
Practice Address - Zip Code:45168-8961
Practice Address - Country:US
Practice Address - Phone:937-213-3248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-28
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH402410163W00000X
KY3011352363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse