Provider Demographics
NPI:1609969823
Name:MATHENY, COLIN O (PA)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:O
Last Name:MATHENY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 THREE RIVERS DR NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-4999
Mailing Address - Country:US
Mailing Address - Phone:706-292-0040
Mailing Address - Fax:706-378-0556
Practice Address - Street 1:100 THREE RIVERS DR NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-4999
Practice Address - Country:US
Practice Address - Phone:706-292-0040
Practice Address - Fax:706-378-0556
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004874363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA902115928BMedicaid
GA902115928AMedicaid
GA902115928DMedicaid
GA902115928CMedicaid
GA902115928CMedicaid
GA4667320001Medicare NSC
GA902115928DMedicaid