Provider Demographics
NPI:1851097208
Name:MOODY, MATTHEW J (FNP)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:MOODY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 STATE HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1530
Mailing Address - Country:US
Mailing Address - Phone:505-827-8535
Mailing Address - Fax:505-508-5284
Practice Address - Street 1:7301 JEFFERSON ST NE STE G
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4363
Practice Address - Country:US
Practice Address - Phone:505-922-9800
Practice Address - Fax:505-508-5284
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM55193363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily