Provider Demographics
NPI:1558335539
Name:MASON, KEVIN CHARLES (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:CHARLES
Last Name:MASON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9600 BROADWAY EXT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-7408
Mailing Address - Country:US
Mailing Address - Phone:405-230-9490
Mailing Address - Fax:405-230-9421
Practice Address - Street 1:9600 BROADWAY EXT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-7408
Practice Address - Country:US
Practice Address - Phone:405-230-9490
Practice Address - Fax:405-230-9421
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200064020AMedicaid
OK200064020AMedicaid
OKP34702Medicare UPIN
OK5439190001Medicare NSC