Basic Information
Provider Information | |||||||||
NPI: | 1720751852 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MATYUS | ||||||||
FirstName: | GABRIELLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 121 BRUNSWICK AVE | ||||||||
Address2: |   | ||||||||
City: | BLOOMSBURY | ||||||||
State: | NJ | ||||||||
PostalCode: | 088043020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4849037097 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1250 S CEDAR CREST BLVD | ||||||||
Address2: |   | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 181036224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104026890 | ||||||||
FaxNumber: | 6104026892 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2021 | ||||||||
LastUpdateDate: | 11/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN691196 | PA | N |   | Nursing Service Providers | Registered Nurse |   | 363LG0600X | SP024603 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
ID | Type | State | Issuer | Description | SP024603 | 01 | PA | STATE LICENSE | OTHER |