Healthcare Provider Details

I. General information

NPI: 1003230723
Provider Name (Legal Business Name): SAM MASON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2014
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N HOSPITAL DR
PAOLA KS
66071-1304
US

IV. Provider business mailing address

310 N HOSPITAL DR
PAOLA KS
66071-1304
US

V. Phone/Fax

Practice location:
  • Phone: 913-294-9175
  • Fax: 913-294-9175
Mailing address:
  • Phone: 913-294-9175
  • Fax: 913-294-9175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number101YP1600X
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: