Healthcare Provider Details

I. General information

NPI: 1932399698
Provider Name (Legal Business Name): NICHOLAS H. MAST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ROWLAND WAY STE 200
NOVATO CA
94945-5041
US

IV. Provider business mailing address

8 ALPINE LILY PL
SAN RAFAEL CA
94903-1090
US

V. Phone/Fax

Practice location:
  • Phone: 415-530-5330
  • Fax: 415-530-5333
Mailing address:
  • Phone: 415-530-5330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number12254
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5401485-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberDR.0061770
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA98951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: