Provider Demographics
NPI:1023415353
Name:MASON, THOMAS RICHARD (PTA)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RICHARD
Last Name:MASON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12251 HIGHWAY 41 N
Mailing Address - Street 2:SUITE A
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47725-7014
Mailing Address - Country:US
Mailing Address - Phone:314-753-2102
Mailing Address - Fax:
Practice Address - Street 1:1095 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3961
Practice Address - Country:US
Practice Address - Phone:618-656-1081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.00100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant