Provider Demographics
NPI:1922557537
Name:MASON, SHANAE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANAE
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 HAWKS BLUFF TRL
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-1812
Mailing Address - Country:US
Mailing Address - Phone:843-368-8355
Mailing Address - Fax:
Practice Address - Street 1:1120 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2013
Practice Address - Country:US
Practice Address - Phone:470-326-5560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1507133V00000X
GA11060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered