MEDICARE: CHARLES MASON FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0000018291	TN
2	163W00000X	Registered Nurse	164018	TN

General Provider Information

NPI Number	:	1073935425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES MASON FNP

Provider Business Mailing Address
First Line	:	8132 CORDOVA RD
Second Line	:	SUITE 102
City	:	CORDOVA
State	:	TN
Zip	:	38016-6005
Country	:	US
Telephone Number	:	901-751-0939
Fax Number	:	901-751-0332

Provider Business Practice Location Address
First Line	:	8132 CORDOVA RD
Second Line	:	SUITE 102
City	:	CORDOVA
State	:	TN
Zip	:	38016-6005
Country	:	US
Telephone Number	:	901-751-0939
Fax Number	:	901-751-0332

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2014
Last Update Date	:	01/28/2014

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