Provider Demographics
NPI:1386824035
Name:MATHIS, CHARLOTTE KATHERINE (PA-C, MPAS)
Entity Type:Individual
Prefix:MS
First Name:CHARLOTTE
Middle Name:KATHERINE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1708 YAKIMA AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5300
Mailing Address - Country:US
Mailing Address - Phone:253-426-4692
Mailing Address - Fax:253-426-6939
Practice Address - Street 1:1708 YAKIMA AVE STE 201
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5300
Practice Address - Country:US
Practice Address - Phone:253-426-4692
Practice Address - Fax:253-426-6939
Is Sole Proprietor?:No
Enumeration Date:2007-11-10
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC0003662363A00000X
VA0110002615363A00000X
DCPA030515363A00000X
WAPA60261126363A00000X
CA52423363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
003207C95OtherMEDICARE IDENTIFICATION NUMBER