Basic Information
| Provider Information | |||||||||
| NPI: | 1770593725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VARGHESE | ||||||||
| FirstName: | MATHEW | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | THREE BARKER AVE | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149491199 | ||||||||
| FaxNumber: | 9149491245 | ||||||||
| Practice Location | |||||||||
| Address1: | THREE BARKER AVE | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149491199 | ||||||||
| FaxNumber: | 9149491245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | F3405031 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 02410240 | 05 | NY | MEDICAID |