Provider Demographics
NPI:1245229111
Name:MASON, GRETCHEN B (PA-C)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:B
Last Name:MASON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:B
Other - Last Name:CHILDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:510 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-6334
Mailing Address - Country:US
Mailing Address - Phone:618-997-6800
Mailing Address - Fax:618-998-9124
Practice Address - Street 1:510 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-6334
Practice Address - Country:US
Practice Address - Phone:618-997-6800
Practice Address - Fax:618-998-9124
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0850003442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant