Provider Demographics
NPI:1992161624
Name:MATHEW, BENITA MERIN (CAA)
Entity type:Individual
Prefix:MISS
First Name:BENITA
Middle Name:MERIN
Last Name:MATHEW
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 PROFESSIONAL DR
Mailing Address - Street 2:#165
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3333
Mailing Address - Country:US
Mailing Address - Phone:770-277-3056
Mailing Address - Fax:
Practice Address - Street 1:575 PROFESSIONAL DR
Practice Address - Street 2:#165
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3333
Practice Address - Country:US
Practice Address - Phone:770-277-3056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7853367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant