Healthcare Provider Details

I. General information

NPI: 1932829579
Provider Name (Legal Business Name): HAILEY AMANDA MASON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2022
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6136 LAKE MURRAY BLVD
LA MESA CA
91942-2502
US

IV. Provider business mailing address

4275 MISSION BAY DR APT 316
SAN DIEGO CA
92109-5764
US

V. Phone/Fax

Practice location:
  • Phone: 877-693-6266
  • Fax:
Mailing address:
  • Phone: 626-483-0299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA64486
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: