Healthcare Provider Details

I. General information

NPI: 1851097208
Provider Name (Legal Business Name): MATTHEW J MOODY FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 JEFFERSON ST NE STE G
ALBUQUERQUE NM
87109-4363
US

IV. Provider business mailing address

4311 STATE HIGHWAY 14
SANTA FE NM
87508-1530
US

V. Phone/Fax

Practice location:
  • Phone: 505-922-9800
  • Fax: 505-508-5284
Mailing address:
  • Phone: 505-827-8535
  • Fax: 505-508-5284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number55193
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: