MEDICARE: MATHESON TAYLOR 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	363A00000X	Physician Assistant	PA15865	TX
2	363A00000X	Physician Assistant	4986	TN

General Provider Information

NPI Number	:	1174267314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATHESON TAYLOR PA-C

Provider Business Mailing Address
First Line	:	1600 HIDDEN BLUFF CT
Second Line	:
City	:	PROSPER
State	:	TX
Zip	:	75078-8789
Country	:	US
Telephone Number	:	615-522-8264
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 S INTERSTATE 35 E STE 101
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76205-6603
Country	:	US
Telephone Number	:	817-668-1360
Fax Number	:

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

Provider Enumeration Date	:	04/25/2022
Last Update Date	:	07/14/2022

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Directions to “ MATHESON TAYLOR PA-C” Practice Location

Language	Start Address	Practice Location

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