Provider Demographics
NPI:1457965402
Name:MASON, TYSHONDRA D (PTA)
Entity Type:Individual
Prefix:
First Name:TYSHONDRA
Middle Name:D
Last Name:MASON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2095 ROYAL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33896-3096
Mailing Address - Country:US
Mailing Address - Phone:863-399-2712
Mailing Address - Fax:
Practice Address - Street 1:610 E BELLA VISTA ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3008
Practice Address - Country:US
Practice Address - Phone:863-688-8591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-06
Last Update Date:2020-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30466225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant