Healthcare Provider Details

I. General information

NPI: 1821434309
Provider Name (Legal Business Name): MATTHEW MOYER APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 PLEASANT ST
CROMWELL CT
06416
US

IV. Provider business mailing address

6 PLEASANT ST
CROMWELL CT
06416-2322
US

V. Phone/Fax

Practice location:
  • Phone: 860-538-3574
  • Fax:
Mailing address:
  • Phone: 860-538-3574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number10.101687
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberTBD
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberTBD
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: