Basic Information
| Provider Information | |||||||||
| NPI: | 1184085284 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHEW | ||||||||
| FirstName: | SHIJI | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146450624 | ||||||||
| FaxNumber: | 2146450078 | ||||||||
| Practice Location | |||||||||
| Address1: | 6363 FOREST PARK RD 7TH FLOOR STE 749 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753901936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146458500 | ||||||||
| FaxNumber: | 2146483775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2016 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA10498 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.