Provider Demographics
NPI:1871174912
Name:MASON, TRAVERICK RAYDRAKEYON
Entity type:Individual
Prefix:
First Name:TRAVERICK
Middle Name:RAYDRAKEYON
Last Name:MASON
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:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:SIMMESPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71369-0069
Mailing Address - Country:US
Mailing Address - Phone:318-717-4399
Mailing Address - Fax:
Practice Address - Street 1:403 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:SIMMESPORT
Practice Address - State:LA
Practice Address - Zip Code:71369
Practice Address - Country:US
Practice Address - Phone:318-717-4399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA485991OtherNON EMERGENCY TRANSPORTATION CODE