Provider Demographics
NPI:1790862415
Name:MATHIS, HEATHER C (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:C
Last Name:MATHIS
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:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-0485
Mailing Address - Country:US
Mailing Address - Phone:803-898-8405
Mailing Address - Fax:
Practice Address - Street 1:220 FAISON DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-3210
Practice Address - Country:US
Practice Address - Phone:803-898-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0293PAMedicaid
SCQ50176Medicare UPIN
SCAA10523350Medicare UPIN
SC0293PAMedicaid
SCAA10523357Medicare UPIN