Provider Demographics
NPI:1811949118
Name:MASON, JOHN DAVID (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:MASON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2713 TOWNWAY RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-1474
Mailing Address - Country:US
Mailing Address - Phone:214-708-0230
Mailing Address - Fax:
Practice Address - Street 1:2713 TOWNWAY RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-1474
Practice Address - Country:US
Practice Address - Phone:214-708-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000630363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK27617Medicare ID - Type UnspecifiedWPS MEDICARE#
R89625Medicare UPIN
ND8HI462Medicare PIN