Provider Demographics
NPI:1386305415
Name:MASON, AUTUMN ROSE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ROSE
Last Name:MASON
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:ROSE
Other - Last Name:FILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-8748
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID45530163WG0000X
ID71748363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice