Provider Demographics
NPI:1720882137
Name:MATHEW, STACY (PA-C)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MATHEW
Suffix:
Gender:
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 1:11300 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33161-6628
Mailing Address - Country:US
Mailing Address - Phone:305-899-3000
Mailing Address - Fax:
Practice Address - Street 1:11300 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33161-6628
Practice Address - Country:US
Practice Address - Phone:305-899-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9119928363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant