Provider Demographics
NPI:1790475150
Name:MAST, AUTUMN TYE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:AUTUMN
Middle Name:TYE
Last Name:MAST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4808 BISHOPS CASTLE DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-1504
Mailing Address - Country:US
Mailing Address - Phone:432-210-3027
Mailing Address - Fax:
Practice Address - Street 1:4808 BISHOPS CASTLE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-1504
Practice Address - Country:US
Practice Address - Phone:432-210-3027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant