Provider Demographics
NPI:1811936446
Name:MATHERNE, DWIGHT D (PAC)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:D
Last Name:MATHERNE
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 1:144 W 134TH ST
Mailing Address - Street 2:
Mailing Address - City:CUT OFF
Mailing Address - State:LA
Mailing Address - Zip Code:70345-4155
Mailing Address - Country:US
Mailing Address - Phone:985-632-6233
Mailing Address - Fax:985-632-7526
Practice Address - Street 1:144 W 134TH ST
Practice Address - Street 2:
Practice Address - City:CUT OFF
Practice Address - State:LA
Practice Address - Zip Code:70345-4155
Practice Address - Country:US
Practice Address - Phone:985-632-6233
Practice Address - Fax:985-632-7526
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.A10369.RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1625957Medicaid
LA5CH34PD54Medicare PIN
LAQ02068Medicare UPIN