Basic Information
| Provider Information | |||||||||
| NPI: | 1336625698 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SARGENT | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | G | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 GLENLAKE PKWY | ||||||||
| Address2: | STE 550 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303287242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553970197 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 ROE AVE | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149051629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077377770 | ||||||||
| FaxNumber: | 6072713686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2018 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 343280 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 343280 | 01 | NY | NYS LICENSE | OTHER |