Provider Demographics
NPI:1730787128
Name:SECALLUS, MICHAEL CHRISTOPHER (FNP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHRISTOPHER
Last Name:SECALLUS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 S WEST ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-1542
Mailing Address - Country:US
Mailing Address - Phone:607-753-3797
Mailing Address - Fax:
Practice Address - Street 1:20 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:NY
Practice Address - Zip Code:13803
Practice Address - Country:US
Practice Address - Phone:607-849-3271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339980-1207Q00000X
NY339980363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine