Provider Demographics
NPI:1891786943
Name:MATHEWS, WAYNE ALLEN (PAC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:ALLEN
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4371
Mailing Address - Country:US
Mailing Address - Phone:217-872-3800
Mailing Address - Fax:217-872-0849
Practice Address - Street 1:250 W KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4371
Practice Address - Country:US
Practice Address - Phone:217-872-3800
Practice Address - Fax:217-872-0849
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL94546Medicare ID - Type UnspecifiedMEDICARE#
ILR78386Medicare UPIN
ILF400105132Medicare PIN
IL970008087Medicare ID - Type UnspecifiedRAILROAD