Healthcare Provider Details

I. General information

NPI: 1144905886
Provider Name (Legal Business Name): MASON PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6965 CUMBERLAND GAP PKWY
HARROGATE TN
37752-8231
US

IV. Provider business mailing address

2017 VAIL DR
GARLAND TX
75044-6790
US

V. Phone/Fax

Practice location:
  • Phone: 423-869-3611
  • Fax:
Mailing address:
  • Phone: 468-888-3048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4050471
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: