Provider Demographics
NPI:1396953196
Name:MASON, NATHAN R (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:R
Last Name:MASON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:10717 W STATE ST
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-6046
Practice Address - Country:US
Practice Address - Phone:208-302-6300
Practice Address - Fax:208-302-6355
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD125936207Q00000X
IDM-15457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500608912Medicaid
OR500608912Medicaid