Provider Demographics
NPI:1508592080
Name:MOELLER, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MOELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 PEARL ST APT 714W
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06103-2456
Mailing Address - Country:US
Mailing Address - Phone:781-588-0401
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06103-0610
Practice Address - Country:US
Practice Address - Phone:860-545-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT176152163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency