MEDICARE: MRS. IRENE DE LA CRUZ MASON P.A.-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	PA16831	CA

General Provider Information

NPI Number	:	1083621593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IRENE DE LA CRUZ MASON P.A.-C

Provider Business Mailing Address
First Line	:	3585 MAPLE ST
Second Line	:	STE 258
City	:	VENTURA
State	:	CA
Zip	:	93003-3504
Country	:	US
Telephone Number	:	805-644-0656
Fax Number	:	805-649-5061

Provider Business Practice Location Address
First Line	:	3585 MAPLE ST
Second Line	:	STE 258
City	:	VENTURA
State	:	CA
Zip	:	93003-3504
Country	:	US
Telephone Number	:	805-644-0656
Fax Number	:	805-649-5061

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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