MEDICARE: MRS. PAMELA DENISE MATHIS

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	3747P1801X	Personal Care Attendant	4866156	AZ

General Provider Information

NPI Number	:	1679975825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PAMELA DENISE MATHIS

Provider Business Mailing Address
First Line	:	11120 W VAN BUREN ST APT 2117
Second Line	:
City	:	AVONDALE
State	:	AZ
Zip	:	85323-7304
Country	:	US
Telephone Number	:	602-243-1773
Fax Number	:	602-276-1984

Provider Business Practice Location Address
First Line	:	11120 W VAN BUREN ST APT 2117
Second Line	:
City	:	AVONDALE
State	:	AZ
Zip	:	85323-7304
Country	:	US
Telephone Number	:	602-243-1773
Fax Number	:	602-276-1984

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

Provider Enumeration Date	:	09/18/2014
Last Update Date	:	09/18/2014

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