Provider Demographics
NPI:1598342610
Name:FISH, MASON M (PA)
Entity type:Individual
Prefix:MR
First Name:MASON
Middle Name:M
Last Name:FISH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2454 N MCMULLEN BOOTH RD STE 501-504
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-1353
Mailing Address - Country:US
Mailing Address - Phone:727-285-8770
Mailing Address - Fax:727-285-8774
Practice Address - Street 1:2454 N MCMULLEN BOOTH RD STE 501-504
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-1353
Practice Address - Country:US
Practice Address - Phone:727-285-8770
Practice Address - Fax:727-285-8774
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1437444023Medicaid