Provider Demographics
NPI:1740283829
Name:MATHIS, AUDREY A (NP)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:A
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 1:4103 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-6600
Mailing Address - Country:US
Mailing Address - Phone:315-637-7800
Mailing Address - Fax:315-637-7808
Practice Address - Street 1:4103 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6600
Practice Address - Country:US
Practice Address - Phone:315-637-7800
Practice Address - Fax:315-637-7808
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320426163W00000X
NYF332143363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02119060Medicaid
NYJ400037457Medicare PIN
S94076Medicare UPIN
NYJ400003504Medicare PIN