Provider Demographics
NPI:1427474220
Name:MATHEW, NISHA (PA)
Entity type:Individual
Prefix:
First Name:NISHA
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL PLZ
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3602
Mailing Address - Country:US
Mailing Address - Phone:203-276-7993
Mailing Address - Fax:203-276-7020
Practice Address - Street 1:1 HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3602
Practice Address - Country:US
Practice Address - Phone:203-276-7993
Practice Address - Fax:203-276-7020
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017233363AS0400X
CT363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03875725Medicaid
NYA400101342OtherMEDICARE PTAN