Provider Demographics
NPI:1114393782
Name:TREZISE, MASON WADE
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:WADE
Last Name:TREZISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1615
Mailing Address - Street 2:
Mailing Address - City:EAGAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85925-1615
Mailing Address - Country:US
Mailing Address - Phone:602-349-0483
Mailing Address - Fax:
Practice Address - Street 1:98 E 7TH PL
Practice Address - Street 2:
Practice Address - City:EAGAR
Practice Address - State:AZ
Practice Address - Zip Code:85925
Practice Address - Country:US
Practice Address - Phone:602-349-0483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer