Provider Demographics
NPI:1578189387
Name:MASON, ERIC DYLAN (IDMT)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:DYLAN
Last Name:MASON
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 BROADWAY ST APT B
Mailing Address - Street 2:
Mailing Address - City:EIELSON AFB
Mailing Address - State:AK
Mailing Address - Zip Code:99702-1344
Mailing Address - Country:US
Mailing Address - Phone:573-247-7696
Mailing Address - Fax:
Practice Address - Street 1:2630 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EIELSON AFB
Practice Address - State:AK
Practice Address - Zip Code:99702-2301
Practice Address - Country:US
Practice Address - Phone:907-377-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians