Basic Information
Provider Information | |||||||||
NPI: | 1649690967 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MASON | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: | NANCE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NANCE | ||||||||
OtherFirstName: | EMILY | ||||||||
OtherMiddleName: | WIDNER | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2727 PACES FERRY RD SE STE 1-1100 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303396151 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4702713418 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 35 COLLIER RD NW STE 635 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303091611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043673014 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2014 | ||||||||
LastUpdateDate: | 12/23/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/23/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 081102 | GA | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 208M00000X | 081102 | GA | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | 081102 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.