Basic Information
| Provider Information | |||||||||
| NPI: | 1811124084 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MASON NURSE PRACTITIONER IN FAMILY MEDICINE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | NORTH TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2131 SAWYER DR | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | NIAGARA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 143042979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162164424 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2009 | ||||||||
| LastUpdateDate: | 06/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | MASON | ||||||||
| AuthorizedOfficialFirstName: | VERONICA | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7162164424 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
| NPICertificationDate: | 06/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | 333243 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01365920 | 05 | NY | MEDICAID |