Healthcare Provider Details

I. General information

NPI: 1184459133
Provider Name (Legal Business Name): MASON BORUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N 3RD STREET HEALTH NORTH BUILDING, 3RD FLOOR
PHOENIX AZ
85004
US

IV. Provider business mailing address

550 N 3RD STREET HEALTH NORTH BUILDING, 3RD FLOOR
PHOENIX AZ
85004
US

V. Phone/Fax

Practice location:
  • Phone: 602-496-0907
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number14505
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number205406
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: