Basic Information
| Provider Information | |||||||||
| NPI: | 1164426110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASON | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WINTER | ||||||||
| OtherFirstName: | JULIA | ||||||||
| OtherMiddleName: | R. | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 24850 SE STARK ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970308316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034910714 | ||||||||
| FaxNumber: | 5036742834 | ||||||||
| Practice Location | |||||||||
| Address1: | 24850 SE STARK ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970308316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034910714 | ||||||||
| FaxNumber: | 5036742834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 163455 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 500660445 | 05 | OR | MEDICAID | 34053400 | 05 | WI | MEDICAID |