Healthcare Provider Details

I. General information

NPI: 1730909961
Provider Name (Legal Business Name): RICHARD MATATOV FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/14/2024
Certification Date: 10/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3446 VERNON BLVD APT E316
ASTORIA NY
11106-5404
US

IV. Provider business mailing address

3446 VERNON BLVD APT E316
ASTORIA NY
11106-5404
US

V. Phone/Fax

Practice location:
  • Phone: 646-403-0619
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF355218-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: