Provider Demographics
NPI:1053446690
Name:MATHIS, MARY STEPHENS (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:STEPHENS
Last Name:MATHIS
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-3107
Practice Address - Street 1:1310 COUNTY ROAD 210 W
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259
Practice Address - Country:US
Practice Address - Phone:904-824-4407
Practice Address - Fax:904-390-7459
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2023-08-15
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Provider Licenses
StateLicense IDTaxonomies
FLPA9103761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00944724OtherRR MEDICARE
FLP00944724OtherRR MEDICARE