Provider Demographics
NPI:1528656337
Name:MASON, KENNETH THOMAS JR (PA-C)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:THOMAS
Last Name:MASON
Suffix:JR
Gender:M
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 1:200 W MONTGOMERY AVE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-1416
Mailing Address - Country:US
Mailing Address - Phone:610-228-0816
Mailing Address - Fax:
Practice Address - Street 1:200 W MONTGOMERY AVE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-1416
Practice Address - Country:US
Practice Address - Phone:610-228-0816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant