Provider Demographics
NPI:1154646172
Name:MATHEW, CARL DUANE (LPN)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:DUANE
Last Name:MATHEW
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 BAKEMAN ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-3333
Mailing Address - Country:US
Mailing Address - Phone:315-598-2046
Mailing Address - Fax:
Practice Address - Street 1:96 BAKEMAN ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-3333
Practice Address - Country:US
Practice Address - Phone:315-598-2046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY289729-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse