Provider Demographics
NPI:1215713672
Name:HADDOCK, MASON
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:
Last Name:HADDOCK
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 1:555 FLETCHER AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-1376
Mailing Address - Country:US
Mailing Address - Phone:573-795-2534
Mailing Address - Fax:
Practice Address - Street 1:555 FLETCHER AVE APT 1
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-1376
Practice Address - Country:US
Practice Address - Phone:573-795-2534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider