Provider Demographics
NPI:1043525587
Name:MORAN, MATTHEW GABRIEL (NP)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:GABRIEL
Last Name:MORAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:MATT
Other - Middle Name:G
Other - Last Name:MORAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:20 LOMBARDY LN
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-1912
Mailing Address - Country:US
Mailing Address - Phone:562-478-0081
Mailing Address - Fax:
Practice Address - Street 1:555 E TACHEVAH DR STE 1E201
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-5733
Practice Address - Country:US
Practice Address - Phone:760-299-6487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19574363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043525587Medicare UPIN