Provider Demographics
NPI:1073534814
Name:MATHENY, PATRICK (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:MATHENY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71230
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19176-6230
Mailing Address - Country:US
Mailing Address - Phone:703-383-6469
Mailing Address - Fax:
Practice Address - Street 1:3620 JOSEPH SIEWICK DR
Practice Address - Street 2:STE 100
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1757
Practice Address - Country:US
Practice Address - Phone:703-810-5223
Practice Address - Fax:703-810-5403
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA110840150363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R23292Medicare UPIN
S44394C9SMedicare ID - Type Unspecified
538695Medicare PIN