Provider Demographics
NPI:1902980469
Name:MASON, LAURA J (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:MASON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1547
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1547
Mailing Address - Country:US
Mailing Address - Phone:208-529-2352
Mailing Address - Fax:208-528-3332
Practice Address - Street 1:1995 E 17TH ST STE 2
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6493
Practice Address - Country:US
Practice Address - Phone:208-529-2352
Practice Address - Fax:208-528-3332
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP386A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805725800Medicaid
P00152836OtherRAILROAD MEDICARE
P00152836OtherRAILROAD MEDICARE
S88529Medicare UPIN