Basic Information
| Provider Information | |||||||||
| NPI: | 1881688257 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIAS | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11850 W MARKET PL | ||||||||
| Address2: | SUITE P | ||||||||
| City: | FULTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207592670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013408339 | ||||||||
| FaxNumber: | 2404855407 | ||||||||
| Practice Location | |||||||||
| Address1: | 15225 SHADY GROVE RD | ||||||||
| Address2: | SUITE 306B | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208503254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404014230 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C01617 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | C0001617 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.