Healthcare Provider Details

I. General information

NPI: 1003402389
Provider Name (Legal Business Name): EVAN F MATHENY BS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 9TH ST STE F
VIENNA WV
26105-2176
US

IV. Provider business mailing address

1104 26TH ST APT 3
VIENNA WV
26105-2371
US

V. Phone/Fax

Practice location:
  • Phone: 304-485-0791
  • Fax:
Mailing address:
  • Phone: 814-232-6004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: