Healthcare Provider Details

I. General information

NPI: 1184074643
Provider Name (Legal Business Name): GLENN MASON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 LEIGH DR
COLUMBUS MS
39705-3014
US

IV. Provider business mailing address

670 LEIGH DR
COLUMBUS MS
39705-3014
US

V. Phone/Fax

Practice location:
  • Phone: 662-328-1012
  • Fax: 662-328-1507
Mailing address:
  • Phone: 662-328-1012
  • Fax: 662-328-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR888556
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: