Provider Demographics
NPI:1427481571
Name:MATHEW, NICOLE RACHEL (PA-C)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:RACHEL
Last Name:MATHEW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RACHEL
Other - Last Name:PETER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:251 E HURON ST
Mailing Address - Street 2:SUITE 16-738
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2908
Mailing Address - Country:US
Mailing Address - Phone:312-926-5924
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:SUITE 16-738
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-926-5924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004704363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085004704OtherLICENSE