MEDICARE: MRS. MIMI B MATHEWS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA14481	CA

General Provider Information

NPI Number	:	1730202409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MIMI B MATHEWS PA-C

Provider Business Mailing Address
First Line	:	751 S WEIR CANYON RD
Second Line	:	SUITE 167
City	:	ANAHEIM
State	:	CA
Zip	:	92808-4780
Country	:	US
Telephone Number	:	714-974-0611
Fax Number	:	714-974-5019

Provider Business Practice Location Address
First Line	:	751 S WEIR CANYON RD
Second Line	:	SUITE 167
City	:	ANAHEIM
State	:	CA
Zip	:	92808-1962
Country	:	US
Telephone Number	:	714-974-0611
Fax Number	:	714-974-5019

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	02/10/2015

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