Basic Information
| Provider Information | |||||||||
| NPI: | 1285910059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHENIA | ||||||||
| FirstName: | JEREMY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1715 REYNOLDS DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619203154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173431974 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4241 HWY 14 W | ||||||||
| Address2: | |||||||||
| City: | CHRISTOPHER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628220155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187242401 | ||||||||
| FaxNumber: | 6187244628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2011 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 085004144 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 085-004144 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.