Provider Demographics
NPI:1396997136
Name:MATHIAS, MEGAN KELLEY (PA-C)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:KELLEY
Last Name:MATHIAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:KELLEY
Other - Last Name:EVERETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 759047
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9047
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:8105 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-3905
Practice Address - Country:US
Practice Address - Phone:443-573-0564
Practice Address - Fax:443-573-0565
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003894363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD149619OtherMEDICARE GROUP PTAN
MD945LOtherMEDICARE GROUP PTAN
MD149619OtherMEDICARE GROUP PTAN
MD945LOtherMEDICARE GROUP PTAN