Provider Demographics
NPI:1669090460
Name:MATHEW, JAIBA PAUL (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:JAIBA
Middle Name:PAUL
Last Name:MATHEW
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 STREAMVIEW WAY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-5954
Mailing Address - Country:US
Mailing Address - Phone:832-692-8396
Mailing Address - Fax:
Practice Address - Street 1:980 JOHNSON FY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1626
Practice Address - Country:US
Practice Address - Phone:404-252-0256
Practice Address - Fax:404-252-0256
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN207189363LA2200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health