Healthcare Provider Details

I. General information

NPI: 1235001330
Provider Name (Legal Business Name): MATTHEW URBAN PMHNP - BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2025
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9655 SCHMIDT LAKE RD STE 150
PLYMOUTH MN
55442-4507
US

IV. Provider business mailing address

956 150TH AVE NE
HAM LAKE MN
55304-6041
US

V. Phone/Fax

Practice location:
  • Phone: 763-559-1640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number13373
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: