Provider Demographics
NPI:1992967954
Name:MASON, MIRRANDA SAINT (LMP)
Entity type:Individual
Prefix:
First Name:MIRRANDA
Middle Name:SAINT
Last Name:MASON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8950 GRAVELLY LAKE DR SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3110
Mailing Address - Country:US
Mailing Address - Phone:253-581-1533
Mailing Address - Fax:
Practice Address - Street 1:8950 GRAVELLY LAKE DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3110
Practice Address - Country:US
Practice Address - Phone:253-581-1533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018198174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist