Provider Demographics
NPI:1851603062
Name:HICKS, MASON H (PA-C)
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:H
Last Name:HICKS
Suffix:
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 1:1017 FAIRNIE AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-5313
Mailing Address - Country:US
Mailing Address - Phone:843-822-0711
Mailing Address - Fax:
Practice Address - Street 1:5147 N 9TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8770
Practice Address - Country:US
Practice Address - Phone:850-494-9000
Practice Address - Fax:850-416-1912
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMPA1559363AS0400X
FLPA9111053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0242695-00Medicaid
FLPA9111053OtherFL MEDICAL LICENSE
AA62098552Medicare PIN