Basic Information
| Provider Information | |||||||||
| NPI: | 1710922695 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASTERSON | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 698 FEATHERSTONE RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611076303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153983277 | ||||||||
| FaxNumber: | 8159861448 | ||||||||
| Practice Location | |||||||||
| Address1: | 698 FEATHERSTONE RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611076303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153983277 | ||||||||
| FaxNumber: | 8159861448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 05/18/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 085.000679 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.