Healthcare Provider Details

I. General information

NPI: 1891417390
Provider Name (Legal Business Name): MASON LEE DONNELL PHD, PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 03/07/2026
Certification Date: 03/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CIVIC CENTER DR
SAN RAFAEL CA
94903-4171
US

IV. Provider business mailing address

1141 PEAR TREE LN STE 100
NAPA CA
94558-6485
US

V. Phone/Fax

Practice location:
  • Phone: 415-492-3333
  • Fax:
Mailing address:
  • Phone: 707-254-1770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number62685
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: