MEDICARE: DR. TRACY MASON

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1104173459
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACY MASON

Provider Business Mailing Address
First Line	:	PO BOX 12236
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23541-0236
Country	:	US
Telephone Number	:	757-831-2176
Fax Number	:

Provider Business Practice Location Address
First Line	:	4512 MARLWOOD WAY
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-7238
Country	:	US
Telephone Number	:	757-831-2176
Fax Number	:

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

Provider Enumeration Date	:	08/06/2012
Last Update Date	:	08/06/2012

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