Provider Demographics
NPI:1295518447
Name:RANKIN, MASON BRANDON (PA)
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:BRANDON
Last Name:RANKIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-302-9342
Mailing Address - Fax:
Practice Address - Street 1:6165 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8613
Practice Address - Country:US
Practice Address - Phone:208-302-3500
Practice Address - Fax:208-302-3555
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDPA-2811363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program