Provider Demographics
NPI:1124428362
Name:MASON, NICHOLAS RYAN (DPT)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:RYAN
Last Name:MASON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-2190
Mailing Address - Country:US
Mailing Address - Phone:616-754-7040
Mailing Address - Fax:616-754-7888
Practice Address - Street 1:1330 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2190
Practice Address - Country:US
Practice Address - Phone:616-754-7040
Practice Address - Fax:616-754-7888
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016902225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist