Healthcare Provider Details

I. General information

NPI: 1598243149
Provider Name (Legal Business Name): KAYLEE MASON HERRERO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLEE MASON MUELLER

II. Dates (important events)

Enumeration Date: 08/04/2018
Last Update Date: 10/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1739 E BEVERLY AVE STE 102
KINGMAN AZ
86409-3593
US

IV. Provider business mailing address

3269 N STOCKTON HILL RD
KINGMAN AZ
86409-3619
US

V. Phone/Fax

Practice location:
  • Phone: 928-681-8693
  • Fax:
Mailing address:
  • Phone: 928-263-4722
  • Fax: 928-263-4794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7227
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: