Provider Demographics
NPI:1528173028
Name:MASON, NICOLE (PA-C)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:MASON
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 1:8422 N 123RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-2130
Mailing Address - Country:US
Mailing Address - Phone:918-858-4353
Mailing Address - Fax:866-246-2942
Practice Address - Street 1:8422 N 123RD EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-2130
Practice Address - Country:US
Practice Address - Phone:918-858-4353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29422084P0800X, 363A00000X, 363AM0700X
IL085002618363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1528173028Medicaid
ILQ77061Medicare UPIN