Provider Demographics
NPI:1811344369
Name:MASON, JACOB (CRNA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MASON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16712 SAYBROOK LANE #103
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649
Mailing Address - Country:US
Mailing Address - Phone:626-340-3354
Mailing Address - Fax:
Practice Address - Street 1:3638 E OCEAN BLVD APT 1
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-2753
Practice Address - Country:US
Practice Address - Phone:626-340-3354
Practice Address - Fax:626-340-3354
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-14
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000611367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered