Healthcare Provider Details

I. General information

NPI: 1356171763
Provider Name (Legal Business Name): MASON LEE COBB SRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/03/2024
Certification Date: 08/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

11 HOLLAND DR
WINDSOR VA
23487-9218
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-5000
  • Fax:
Mailing address:
  • Phone: 757-374-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001277840
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0001277840
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: