Provider Demographics
NPI:1962823229
Name:MOORE, MATTHEW MICHAEL (CRNA)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:MOORE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SLOCUM MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-1854
Mailing Address - Country:US
Mailing Address - Phone:508-277-8365
Mailing Address - Fax:
Practice Address - Street 1:17 SLOCUM MEADOW LN
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-1854
Practice Address - Country:US
Practice Address - Phone:508-277-8365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2024-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001236898163W00000X
MARN2336114367500000X
VA0024171408367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110163071AMedicaid