Provider Demographics
NPI:1982064184
Name:MASON, SPENCER
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:MASON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 S MAIN
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:SD
Mailing Address - Zip Code:57555
Mailing Address - Country:US
Mailing Address - Phone:605-856-2295
Mailing Address - Fax:
Practice Address - Street 1:161 S MAIN
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:SD
Practice Address - Zip Code:57555
Practice Address - Country:US
Practice Address - Phone:605-856-2295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant