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General NPI Number Information
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NPI Number | 1053162735
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Entity Type | Individual
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Provider Name | MATTHEW BOOTH CRNP
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Gender | Male
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Dates
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Enumeration Date | 03/29/2024
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Last Update Date | 03/29/2024
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Provider Practice Location Address
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Address Line | 480 PIERCE ST STE 320
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City | KINGSTON
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State | PA
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Zip | 18704-5512
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Country | US
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Telephone | 570-479-1627
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Fax |
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Provider Business Mailing Address
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Address Line | 510 ISABELLE CT APT B
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City | EDWARDSVILLE
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State | PA
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Zip | 18704-5901
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Country | US
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Telephone | 570-479-1627
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | SP029539
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License Number State | PA
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