MEDICARE: MR. TYLER JAMES 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	163W00000X	Registered Nurse	402410	OH
2	363L00000X	Nurse Practitioner	3011352	KY

General Provider Information

NPI Number	:	1659811396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TYLER JAMES MASON

Provider Business Mailing Address
First Line	:	5942 HUFF HILL RD
Second Line	:
City	:	RUSSELLVILLE
State	:	OH
Zip	:	45168-8961
Country	:	US
Telephone Number	:	937-213-3248
Fax Number	:

Provider Business Practice Location Address
First Line	:	5942 HUFF HILL RD
Second Line	:
City	:	RUSSELLVILLE
State	:	OH
Zip	:	45168-8961
Country	:	US
Telephone Number	:	937-213-3248
Fax Number	:

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

Provider Enumeration Date	:	02/28/2017
Last Update Date	:	06/15/2017

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