MEDICARE: MR. MATTHEW L BALANDA APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	5850	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447651690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW L BALANDA APRN

Provider Business Mailing Address
First Line	:	1389 W MAIN ST STE 205
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06708-3115
Country	:	US
Telephone Number	:	203-755-7080
Fax Number	:	203-346-6244

Provider Business Practice Location Address
First Line	:	1389 W MAIN ST STE 205
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06708-3115
Country	:	US
Telephone Number	:	203-755-7080
Fax Number	:	203-346-6244

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2014
Last Update Date	:	04/25/2018

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