Provider Demographics
NPI:1922648419
Name:HALLORAN, MATTHEW JACOB (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JACOB
Last Name:HALLORAN
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:PO BOX 23
Mailing Address - Street 2:
Mailing Address - City:CALLICOON CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:12724-0023
Mailing Address - Country:US
Mailing Address - Phone:845-594-7504
Mailing Address - Fax:
Practice Address - Street 1:4400 VESTAL PKWY E
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13902-4400
Practice Address - Country:US
Practice Address - Phone:607-777-4954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY527947163W00000X
NY347909363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse