Provider Demographics
NPI:1003238684
Name:MORAES, MATT (AA)
Entity Type:Individual
Prefix:MR
First Name:MATT
Middle Name:
Last Name:MORAES
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6750 NW 45TH WAY
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-1927
Mailing Address - Country:US
Mailing Address - Phone:305-409-3221
Mailing Address - Fax:
Practice Address - Street 1:410 S 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4203
Practice Address - Country:US
Practice Address - Phone:863-679-6814
Practice Address - Fax:863-679-6859
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA212367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant