Provider Demographics
NPI:1699850529
Name:MATHIEU, ALLEN E (PAC,ATC,MS)
Entity Type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:E
Last Name:MATHIEU
Suffix:
Gender:M
Credentials:PAC,ATC,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 N NEW BALLAS CT
Mailing Address - Street 2:STE130
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-9510
Mailing Address - Country:US
Mailing Address - Phone:314-997-1777
Mailing Address - Fax:314-977-6277
Practice Address - Street 1:845 N NEW BALLAS CT
Practice Address - Street 2:STE130
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-9510
Practice Address - Country:US
Practice Address - Phone:314-997-1777
Practice Address - Fax:314-977-6277
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102451363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102451OtherPA LICENSE