Healthcare Provider Details

I. General information

NPI: 1043028269
Provider Name (Legal Business Name): MATTHEW TIBERIA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2024
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 PEACHTREE LN
ROSLYN HEIGHTS NY
11577-2415
US

IV. Provider business mailing address

41 PEACHTREE LN
ROSLYN HEIGHTS NY
11577-2415
US

V. Phone/Fax

Practice location:
  • Phone: 516-884-3462
  • Fax:
Mailing address:
  • Phone: 516-884-3462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number68466401
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: