Provider Demographics
NPI:1285270645
Name:PRIVETT, MATTHEW A (FNP)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:A
Last Name:PRIVETT
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 ROOT RD
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-9730
Mailing Address - Country:US
Mailing Address - Phone:585-395-9158
Mailing Address - Fax:
Practice Address - Street 1:281 ROOT RD
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-9730
Practice Address - Country:US
Practice Address - Phone:585-395-9158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY485518-1163W00000X
NYF346519363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty