Provider Demographics
NPI:1922244532
Name:MASON, SUSAN MAUD (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MAUD
Last Name:MASON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44456 PENBROOK LN
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-5625
Mailing Address - Country:US
Mailing Address - Phone:310-634-7373
Mailing Address - Fax:951-303-2371
Practice Address - Street 1:44456 PENBROOK LN
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-5625
Practice Address - Country:US
Practice Address - Phone:310-634-7373
Practice Address - Fax:951-303-2371
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-02
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA613017363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAUNKNOWNMedicaid