Provider Demographics
NPI:1508343450
Name:REISTETTER, MICHAEL PATRICK (FNP-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
Last Name:REISTETTER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-1108
Mailing Address - Country:US
Mailing Address - Phone:607-821-9253
Mailing Address - Fax:
Practice Address - Street 1:17 CHENANGO BRIDGE RD.
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901
Practice Address - Country:US
Practice Address - Phone:607-772-2995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF343259-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine