Healthcare Provider Details

I. General information

NPI: 1922557537
Provider Name (Legal Business Name): SHANAE MASON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 PEACHTREE INDUSTRIAL BLVD
SUWANEE GA
30024-2013
US

IV. Provider business mailing address

2260 HAWKS BLUFF TRL
LAWRENCEVILLE GA
30044-1812
US

V. Phone/Fax

Practice location:
  • Phone: 470-326-5560
  • Fax:
Mailing address:
  • Phone: 843-368-8355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11060
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1507
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: