Provider Demographics
NPI:1235130519
Name:GOATER-MATHIS, LAUREN E (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:E
Last Name:GOATER-MATHIS
Suffix:
Gender:F
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 1:3 RIVERSIDE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016
Mailing Address - Country:US
Mailing Address - Phone:540-224-5170
Mailing Address - Fax:540-985-9612
Practice Address - Street 1:3 RIVERSIDE CIRCLE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016
Practice Address - Country:US
Practice Address - Phone:540-224-5170
Practice Address - Fax:540-985-9612
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001413363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010260558Medicaid
VAP82871Medicare UPIN
VA010260558Medicaid
012815C19Medicare PIN
VA970000621Medicare PIN