Healthcare Provider Details

I. General information

NPI: 1528173028
Provider Name (Legal Business Name): NICOLE MASON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8422 N 123RD EAST AVE
OWASSO OK
74055-2130
US

IV. Provider business mailing address

8422 N 123RD EAST AVE
OWASSO OK
74055-2130
US

V. Phone/Fax

Practice location:
  • Phone: 918-858-4353
  • Fax:
Mailing address:
  • Phone: 918-858-4353
  • Fax: 866-246-2942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2942
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002618
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2942
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2942
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: