Provider Demographics
NPI:1336625698
Name:SARGENT, MATTHEW G
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:G
Last Name:SARGENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 GLENLAKE PKWY
Mailing Address - Street 2:STE 550
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-7242
Mailing Address - Country:US
Mailing Address - Phone:855-397-0197
Mailing Address - Fax:
Practice Address - Street 1:600 ROE AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1629
Practice Address - Country:US
Practice Address - Phone:607-737-7770
Practice Address - Fax:607-271-3686
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343280363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY343280OtherNYS LICENSE