Healthcare Provider Details

I. General information

NPI: 1790534584
Provider Name (Legal Business Name): MATTHEW ANDREW HOLBOK FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5496 E TAFT RD STE A
NORTH SYRACUSE NY
13212-3780
US

IV. Provider business mailing address

PO BOX 510
SYRACUSE NY
13214-0510
US

V. Phone/Fax

Practice location:
  • Phone: 315-552-6700
  • Fax: 315-552-6701
Mailing address:
  • Phone: 315-703-3484
  • Fax: 315-703-3487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number351877
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: