Healthcare Provider Details

I. General information

NPI: 1174062491
Provider Name (Legal Business Name): MATTHEW HISLOP PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CENTRAL PARK S SUITE 107
NEW YORK NY
10019-1436
US

IV. Provider business mailing address

200 CENTRAL PARK S SUITE 107
NEW YORK NY
10019-1436
US

V. Phone/Fax

Practice location:
  • Phone: 212-262-2500
  • Fax: 212-765-3210
Mailing address:
  • Phone: 212-262-2500
  • Fax: 212-765-3210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number020477
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: