Provider Demographics
NPI:1407319163
Name:MOYLAN, MICHAEL JOSEPH JR (APRN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:MOYLAN
Suffix:JR
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 STANIFORD ST FL 2
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-3105
Mailing Address - Country:US
Mailing Address - Phone:401-421-8800
Mailing Address - Fax:401-421-2492
Practice Address - Street 1:148 W RIVER ST STE 3
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2615
Practice Address - Country:US
Practice Address - Phone:401-421-6306
Practice Address - Fax:401-453-0330
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN02009363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty