Provider Demographics
NPI:1689127508
Name:MASON, CRAIG R (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:R
Last Name:MASON
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:15757 WC MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-7327
Practice Address - Country:US
Practice Address - Phone:804-858-0220
Practice Address - Fax:804-419-0127
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210405225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN
VA1689127508OtherMEDICAID QMB PROVIDER ID
VA1689127508OtherMEDICAID QMB PROVIDER ID