Provider Demographics
NPI:1184285496
Name:MATHEW, JATHA JOHN (NP)
Entity type:Individual
Prefix:MRS
First Name:JATHA
Middle Name:JOHN
Last Name:MATHEW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:JATHA
Other - Middle Name:SUSAN
Other - Last Name:MATHEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD FL 5
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4295
Practice Address - Country:US
Practice Address - Phone:864-455-4411
Practice Address - Fax:864-455-4480
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22785208M00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP6128Medicaid