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:
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Mailing Address - Street 1:12568 BROADWAY ST STE 160
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-8969
Mailing Address - Country:US
Mailing Address - Phone:832-619-1669
Mailing Address - Fax:
Practice Address - Street 1:12568 BROADWAY ST STE 160
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8969
Practice Address - Country:US
Practice Address - Phone:832-619-1669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant