Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 11020056A | IN |
NPI | 1003309378 |
---|---|
Provider Name | Rebecca Mason |
First Address | Fort Wayne, IN 46845-1701 |
Second Address | Fort Wayne, IN 46804-5784 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2018 |
Last Update Date | 01/07/2021 |