Provider Demographics
NPI:1760017420
Name:MASON, DALLAS TRISTAN (PA)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:TRISTAN
Last Name:MASON
Suffix:
Gender:M
Credentials:PA
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Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:520 RILEY PL APT B
Mailing Address - Street 2:
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-1633
Mailing Address - Country:US
Mailing Address - Phone:407-373-9416
Mailing Address - Fax:
Practice Address - Street 1:650 HUEBNER RD
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-4030
Practice Address - Country:US
Practice Address - Phone:407-373-9416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant