Provider Demographics
NPI:1043826092
Name:MASON, KRISTINA ROSE
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ROSE
Last Name:MASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15211 ROSEMARY BLVD
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18501 ROTUNDA DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3891
Practice Address - Country:US
Practice Address - Phone:313-996-1951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704292047363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics