Healthcare Provider Details

I. General information

NPI: 1962778399
Provider Name (Legal Business Name): BETH MATHIS RUIZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 UNION AVENUE, 4 SHORB TOWER
MEMPHIS TN
38104-3415
US

IV. Provider business mailing address

1211 UNION AVE STE 330
MEMPHIS TN
38104-6655
US

V. Phone/Fax

Practice location:
  • Phone: 901-478-9183
  • Fax: 901-478-8957
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4671
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA07629
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4671
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: