Provider Demographics
NPI:1548842065
Name:MASON, MICHELLE LITA (PA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LITA
Last Name:MASON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2373 G RD STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-1006
Mailing Address - Country:US
Mailing Address - Phone:970-243-3061
Mailing Address - Fax:970-245-8369
Practice Address - Street 1:2373 G RD STE 200
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1006
Practice Address - Country:US
Practice Address - Phone:970-243-3061
Practice Address - Fax:970-245-8369
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006733363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical