Provider Demographics
NPI:1366060691
Name:HUSSONG, MATTHEW ALLEN (AGNP-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALLEN
Last Name:HUSSONG
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-6102
Mailing Address - Country:US
Mailing Address - Phone:212-746-1664
Mailing Address - Fax:212-746-4888
Practice Address - Street 1:7150 CLEARVISTA DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1695
Practice Address - Country:US
Practice Address - Phone:317-621-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28213561A163W00000X
NY311191363LG0600X
IN71010218A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse