1518591312 NPI number — VICTORIA MATHIS PA-C

Table of content: VICTORIA MATHIS PA-C (NPI 1518591312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518591312 NPI number — VICTORIA MATHIS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHIS
Provider First Name:
VICTORIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMSON
Provider Other First Name:
VICTORIA
Provider Other Middle Name:
FAITH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518591312
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1815 HONEYDEW CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCOEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34761-7705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-313-3734
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
661 E ALTAMONTE DR STE 231
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTAMONTE SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32701-5102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-303-5214
Provider Business Practice Location Address Fax Number:
407-303-5215
Provider Enumeration Date:
03/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9112913 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: PA9112913 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 106428000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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