Provider Demographics
NPI:1457045346
Name:MASON II, DERYK (LVN)
Entity Type:Individual
Prefix:MR
First Name:DERYK
Middle Name:
Last Name:MASON II
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11474 TIOGA PEAK CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-8804
Mailing Address - Country:US
Mailing Address - Phone:909-313-1192
Mailing Address - Fax:
Practice Address - Street 1:1241 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3681
Practice Address - Country:US
Practice Address - Phone:909-985-2713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA287724164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse