Provider Demographics
NPI:1386806974
Name:MATHIS, RENE MICHELE (PA)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:MICHELE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-392-3441
Mailing Address - Fax:352-265-1092
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-392-3441
Practice Address - Fax:352-265-0627
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2009-02-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9104628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AM431ZMedicare PIN