Healthcare Provider Details

I. General information

NPI: 1407319163
Provider Name (Legal Business Name): MICHAEL JOSEPH MOYLAN JR. APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 W RIVER ST STE 3
PROVIDENCE RI
02904-2615
US

IV. Provider business mailing address

33 STANIFORD ST FL 2
PROVIDENCE RI
02905-3105
US

V. Phone/Fax

Practice location:
  • Phone: 401-421-6306
  • Fax: 401-453-0330
Mailing address:
  • Phone: 401-421-8800
  • Fax: 401-421-2492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN02009
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: