Provider Demographics
NPI:1487219879
Name:MATTHEWS, MARY ELIZABETH (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3084 LAKECREST CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1972
Mailing Address - Country:US
Mailing Address - Phone:859-639-1210
Mailing Address - Fax:
Practice Address - Street 1:3084 LAKECREST CIR STE 100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1972
Practice Address - Country:US
Practice Address - Phone:859-639-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1487219879Medicaid