Provider Demographics
NPI:1104864933
Name:MATHEY, JAMES A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:A
Last Name:MATHEY
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 1:111 W JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-4102
Mailing Address - Country:US
Mailing Address - Phone:909-213-5768
Mailing Address - Fax:909-824-5171
Practice Address - Street 1:6109 W RAMSEY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3051
Practice Address - Country:US
Practice Address - Phone:951-845-0313
Practice Address - Fax:909-796-4158
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA176450Medicaid
CAOPA176450Medicaid