Healthcare Provider Details

I. General information

NPI: 1699195701
Provider Name (Legal Business Name): EVAN MASON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 DOCTORS PARK
CAPE GIRARDEAU MO
63703-4928
US

IV. Provider business mailing address

70 DOCTORS PARK
CAPE GIRARDEAU MO
63703-4928
US

V. Phone/Fax

Practice location:
  • Phone: 573-334-6071
  • Fax:
Mailing address:
  • Phone: 573-334-6071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2020012721
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: