Provider Demographics
NPI:1194183137
Name:MATHIS, GWENDOLYN (DNP-APRN)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:MATHIS
Suffix:
Gender:
Credentials:DNP-APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W ELLIOT RD STE 107-149
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1328
Mailing Address - Country:US
Mailing Address - Phone:802-287-6030
Mailing Address - Fax:602-584-6216
Practice Address - Street 1:6780 HORIZON RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-2103
Practice Address - Country:US
Practice Address - Phone:972-346-1885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20988363L00000X, 363LF0000X, 363LP0808X
NY834633363LP0808X
TX1142764363LP0808X
TNF0116574363LP2300X
AZ249010363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ093249Medicaid