Provider Demographics
NPI:1659998300
Name:MATHIS, PATRICIA ANN
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:MATHIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 KINGS CREST LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8056
Mailing Address - Country:US
Mailing Address - Phone:919-637-3196
Mailing Address - Fax:
Practice Address - Street 1:8362 SIX FORKS RD STE 203
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5086
Practice Address - Country:US
Practice Address - Phone:919-637-3196
Practice Address - Fax:919-900-7070
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC81-1153748Medicaid