Provider Demographics
NPI:1033680566
Name:GREENWOOD, MATTHEW (APRN)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GREENWOOD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:
Other - Last Name:GREENWOOD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:4901 LANG AVE NE STE 203
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4597
Practice Address - Country:US
Practice Address - Phone:505-982-3113
Practice Address - Fax:505-982-2462
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM54474363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty