Provider Demographics
NPI:1477948578
Name:MATHEW, LIJU
Entity Type:Individual
Prefix:
First Name:LIJU
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 ATRIUM WAY
Mailing Address - Street 2:STE 6
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3917
Mailing Address - Country:US
Mailing Address - Phone:856-206-4500
Mailing Address - Fax:
Practice Address - Street 1:3257 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5644
Practice Address - Country:US
Practice Address - Phone:215-634-3976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR16635300163W00000X
PASP014671363LF0000X, 363LP2300X
NJ26NJ00578100363LF0000X, 363LP0808X, 363LP2300X
PASP027204363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care