Provider Demographics
NPI:1053162735
Name:BOOTH, MATTHEW (CRNP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BOOTH
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 ISABELLE CT APT B
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5901
Mailing Address - Country:US
Mailing Address - Phone:570-479-1627
Mailing Address - Fax:
Practice Address - Street 1:480 PIERCE ST STE 320
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5512
Practice Address - Country:US
Practice Address - Phone:570-479-1627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP029539363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health