Provider Demographics
NPI:1053503276
Name:MATHIAS, TRINA VERONICA (LPN)
Entity type:Individual
Prefix:MS
First Name:TRINA
Middle Name:VERONICA
Last Name:MATHIAS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MIRAGE LN
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-6924
Mailing Address - Country:US
Mailing Address - Phone:315-288-5111
Mailing Address - Fax:
Practice Address - Street 1:23 MIRAGE LN
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:NY
Practice Address - Zip Code:13041-6924
Practice Address - Country:US
Practice Address - Phone:315-288-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-12
Last Update Date:2007-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2447901164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02211301Medicare PIN