Provider Demographics
NPI:1801839725
Name:MATHEWS, MARK S (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:700 SLEATER KINNEY RD SE
Mailing Address - Street 2:PMB 254
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1113
Mailing Address - Country:US
Mailing Address - Phone:360-426-8398
Mailing Address - Fax:360-426-0413
Practice Address - Street 1:700 SLEATER KINNEY RD SE
Practice Address - Street 2:PMB 254
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1150
Practice Address - Country:US
Practice Address - Phone:360-426-8398
Practice Address - Fax:360-426-0413
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAPA1002175363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAR32161Medicare UPIN
WAGAB13352Medicare ID - Type UnspecifiedMEDICARE ID NUMBER