Provider Demographics
NPI:1710989371
Name:MOREN, MATTHEW (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MOREN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 SAVANNA DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-7513
Mailing Address - Country:US
Mailing Address - Phone:859-582-3840
Mailing Address - Fax:
Practice Address - Street 1:795 EASTERN BYP
Practice Address - Street 2:BLDG 2 STE 6
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2406
Practice Address - Country:US
Practice Address - Phone:859-625-1879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.08833-NA367500000X
KY3004199367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2690262Medicaid
KY74006750Medicaid
OH2690262Medicaid
KY0943020Medicare ID - Type Unspecified
KY74006750Medicaid
OH2690262Medicaid
KYK045856Medicare PIN