Provider Demographics
NPI:1285910059
Name:MATHENIA, JEREMY (PA-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:MATHENIA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 RED HOOK PLZ STE 205
Mailing Address - Street 2:
Mailing Address - City:ST THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00802-1346
Mailing Address - Country:US
Mailing Address - Phone:340-775-2303
Mailing Address - Fax:
Practice Address - Street 1:6500 RED HOOK PLZ STE 205
Practice Address - Street 2:
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802-1346
Practice Address - Country:US
Practice Address - Phone:340-775-2303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-004144363A00000X
IL085004144363AM0700X
VI363AM0700X
VI105363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant