Provider Demographics
NPI:1275815870
Name:MASON, STEPHANIE M (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:MASON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:M
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7070 E DR N
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49014-8562
Mailing Address - Country:US
Mailing Address - Phone:269-660-1670
Mailing Address - Fax:269-660-0666
Practice Address - Street 1:7070 E DR N
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49014-8562
Practice Address - Country:US
Practice Address - Phone:269-660-1670
Practice Address - Fax:269-660-0666
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006113363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM97310021Medicare PIN