Provider Demographics
NPI:1457907610
Name:MASON, ERICKA JOY (PA)
Entity type:Individual
Prefix:
First Name:ERICKA
Middle Name:JOY
Last Name:MASON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERICKA
Other - Middle Name:JOY
Other - Last Name:DEHAVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:
Practice Address - Street 1:2235 MAYFAIR DR
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4519
Practice Address - Country:US
Practice Address - Phone:270-688-1500
Practice Address - Fax:270-688-1501
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant