Provider Demographics
NPI:1598243149
Name:HERRERO, KAYLEE MASON (PA)
Entity Type:Individual
Prefix:MRS
First Name:KAYLEE
Middle Name:MASON
Last Name:HERRERO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KAYLEE
Other - Middle Name:MASON
Other - Last Name:MUELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3269 N STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3619
Mailing Address - Country:US
Mailing Address - Phone:928-263-4722
Mailing Address - Fax:928-263-4794
Practice Address - Street 1:1739 E BEVERLY AVE STE 102
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3593
Practice Address - Country:US
Practice Address - Phone:928-681-8693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-04
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant