Provider Demographics
NPI:1821335910
Name:NEBRIJA, MASON WILLIAM (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:WILLIAM
Last Name:NEBRIJA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PETERS CANYON RD STE 120
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1748
Mailing Address - Country:US
Mailing Address - Phone:949-679-3988
Mailing Address - Fax:
Practice Address - Street 1:1 PETERS CANYON RD STE 120
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606
Practice Address - Country:US
Practice Address - Phone:949-679-3988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62209225100000X
CA38877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500724693Medicaid