Provider Demographics
NPI:1245279520
Name:MATHE, MARY ELLEN (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:MATHE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 N MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1870
Mailing Address - Country:US
Mailing Address - Phone:407-897-3499
Mailing Address - Fax:407-894-8746
Practice Address - Street 1:1812 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1870
Practice Address - Country:US
Practice Address - Phone:407-897-3499
Practice Address - Fax:407-894-8746
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009409363A00000X
FLPA9104653363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP98316Medicare UPIN
NYP98316Medicare UPIN