Provider Demographics
NPI:1104209907
Name:MATHESS, GREGORY A (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:MATHESS
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 1:3200 MACCORKLE SEAVE B16
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1227
Mailing Address - Country:US
Mailing Address - Phone:304-388-5848
Mailing Address - Fax:304-388-9654
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:SUITE B16
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-5848
Practice Address - Fax:304-388-9654
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant