Provider Demographics
NPI:1649892563
Name:WHALEN, MATTHEW PHILIP
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PHILIP
Last Name:WHALEN
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 1:188 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-2304
Mailing Address - Country:US
Mailing Address - Phone:631-862-5076
Mailing Address - Fax:
Practice Address - Street 1:188 4TH ST
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780-2304
Practice Address - Country:US
Practice Address - Phone:631-862-5076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program