Provider Demographics
NPI:1720377328
Name:MATHENIA, NICHOLAS RYAN (DO)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RYAN
Last Name:MATHENIA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 SPALDING DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6508
Mailing Address - Country:US
Mailing Address - Phone:630-527-7730
Mailing Address - Fax:
Practice Address - Street 1:120 SPALDING DR
Practice Address - Street 2:SUITE 101
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6508
Practice Address - Country:US
Practice Address - Phone:630-527-7730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL3360965122084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program