Provider Demographics
NPI:1407920523
Name:MATHIAS, PHUONG QUOC (PTA)
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:QUOC
Last Name:MATHIAS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:Q
Other - Last Name:MATHIAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:2831 JAMES CHRISTOPHER DR
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-4217
Mailing Address - Country:US
Mailing Address - Phone:314-770-0904
Mailing Address - Fax:
Practice Address - Street 1:2920 FEE FEE RD
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-1915
Practice Address - Country:US
Practice Address - Phone:314-291-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117691225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant