Provider Demographics
NPI:1316514094
Name:ELLIS, MASON JAMES (DPT)
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:JAMES
Last Name:ELLIS
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 1:1401 S MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-3771
Mailing Address - Country:US
Mailing Address - Phone:641-209-1446
Mailing Address - Fax:641-209-1447
Practice Address - Street 1:1401 S MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-3771
Practice Address - Country:US
Practice Address - Phone:641-209-1446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA106917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist