Provider Demographics
NPI:1356171763
Name:COBB, MASON LEE (SRNA)
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:LEE
Last Name:COBB
Suffix:
Gender:M
Credentials:SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HOLLAND DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:VA
Mailing Address - Zip Code:23487-9218
Mailing Address - Country:US
Mailing Address - Phone:757-374-1860
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:757-953-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001277840163WC0200X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine