Provider Demographics
NPI:1881688257
Name:MATHIAS, KATHERINE S (PA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:S
Last Name:MATHIAS
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 1:11850 W MARKET PL
Mailing Address - Street 2:SUITE P
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2670
Mailing Address - Country:US
Mailing Address - Phone:301-340-8339
Mailing Address - Fax:240-485-5407
Practice Address - Street 1:15225 SHADY GROVE RD
Practice Address - Street 2:SUITE 306B
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3254
Practice Address - Country:US
Practice Address - Phone:240-401-4230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC01617363A00000X
MDC0001617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP64015Medicare UPIN
MD017079B82Medicare PIN
MDP64015Medicare UPIN