Provider Demographics
NPI:1871120105
Name:JOHNSON, MASON GRANT
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:GRANT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2492 OGDEN WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-8575
Mailing Address - Country:US
Mailing Address - Phone:606-213-3034
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE STREET MN 150
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40506-0001
Practice Address - Country:US
Practice Address - Phone:859-323-5261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program