Provider Demographics
NPI:1144392044
Name:MATHER, MIRIAM J (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:J
Last Name:MATHER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MIRIAM
Other - Middle Name:J
Other - Last Name:WITMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1281
Mailing Address - Street 2:4TH & WALNUT STREETS
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-1281
Mailing Address - Country:US
Mailing Address - Phone:717-270-7740
Mailing Address - Fax:717-270-3877
Practice Address - Street 1:4TH & WALNUT STS
Practice Address - Street 2:GOOD SAMARITAN HOSPITAL
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-1281
Practice Address - Country:US
Practice Address - Phone:717-270-7740
Practice Address - Fax:717-270-3877
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50065847OtherCAPITAL BLUE CROSS
PA121005KAGMedicare PIN