Healthcare Provider Details

I. General information

NPI: 1992636716
Provider Name (Legal Business Name): THOMAS MATTHEW MOULD BSN, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 12TH STREET EXT
PRINCETON WV
24740-2329
US

IV. Provider business mailing address

590 LEAH DR
PRINCETON WV
24739-9017
US

V. Phone/Fax

Practice location:
  • Phone: 304-425-9541
  • Fax:
Mailing address:
  • Phone: 304-920-5656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number97135
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: