Provider Demographics
NPI:1285033506
Name:MATHEW, ROYCE (PAC)
Entity Type:Individual
Prefix:
First Name:ROYCE
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:PAC
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 22076
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-2076
Mailing Address - Country:US
Mailing Address - Phone:561-657-4600
Mailing Address - Fax:
Practice Address - Street 1:9401 SW DISCOVERY WAY STE 101
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2381
Practice Address - Country:US
Practice Address - Phone:772-288-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112762363A00000X
NY017786363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical