Healthcare Provider Details

I. General information

NPI: 1407772387
Provider Name (Legal Business Name): MICHAEL FROST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33-57 HARRISON ST
JOHNSON CITY NY
13790-2107
US

IV. Provider business mailing address

399 DIVERS XING
MARATHON NY
13803-3005
US

V. Phone/Fax

Practice location:
  • Phone: 607-345-5812
  • Fax:
Mailing address:
  • Phone: 607-345-5812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number360269
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: