Provider Demographics
NPI:1679060941
Name:MATHEW, REENA (FNP)
Entity Type:Individual
Prefix:
First Name:REENA
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:FNP
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 251382
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-1382
Mailing Address - Country:US
Mailing Address - Phone:972-786-0140
Mailing Address - Fax:972-786-0142
Practice Address - Street 1:4100 W 15TH ST STE 110
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5826
Practice Address - Country:US
Practice Address - Phone:469-408-9558
Practice Address - Fax:888-408-9558
Is Sole Proprietor?:No
Enumeration Date:2018-04-21
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137078363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$Medicaid