Healthcare Provider Details

I. General information

NPI: 1174925879
Provider Name (Legal Business Name): NAICKA D MATHIAS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 W HILLSBORO BLVD SUITE B2
COCONUT CREEK FL
33073-4356
US

IV. Provider business mailing address

2900 CORPORATE WAY D
MIRAMAR FL
33025-3925
US

V. Phone/Fax

Practice location:
  • Phone: 954-418-1683
  • Fax: 954-418-1698
Mailing address:
  • Phone: 954-276-5582
  • Fax: 954-276-0154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9108093
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: