Provider Demographics
NPI:1790800951
Name:MATHIEU, KERRI H (PA)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:H
Last Name:MATHIEU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 GRETCHEN WAY
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-5163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 JEREMIAH V SULLIVAN DR
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-6812
Practice Address - Country:US
Practice Address - Phone:508-672-0107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA239OtherSTATE PA LICENSE