Healthcare Provider Details

I. General information

NPI: 1053045948
Provider Name (Legal Business Name): MATTHEW DAVID MICHAUD FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W CAMINO CASA VERDE STE 100
GREEN VALLEY AZ
85614-3569
US

IV. Provider business mailing address

PO BOX 22224
BELFAST ME
04915-4473
US

V. Phone/Fax

Practice location:
  • Phone: 520-625-1760
  • Fax: 520-648-9496
Mailing address:
  • Phone: 469-803-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number279320
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: