=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205580701
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEOPHILUS MASON FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2022
-----------------------------------------------------
Last Update Date | 12/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 W BONITA AVE STE 100
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91767-1863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-392-2002
-----------------------------------------------------
Fax | 626-795-4768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 W BONITA AVE STE 100
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91767-1863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-392-2002
-----------------------------------------------------
Fax | 626-795-4768
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209023392
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | NP95029519
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------