Provider Demographics
NPI:1508016361
Name:MATHIS, ELIZABETH R (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:MATHIS
Suffix:
Gender:F
Credentials:NP
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 1038
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-1038
Mailing Address - Country:US
Mailing Address - Phone:706-660-6410
Mailing Address - Fax:
Practice Address - Street 1:710 CENTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1527
Practice Address - Country:US
Practice Address - Phone:706-571-1220
Practice Address - Fax:706-571-1070
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN160912363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202735123DMedicaid
GA202735123DMedicaid