Provider Demographics
NPI:1780912246
Name:MOORE, MATTHEW RYAN (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RYAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 S LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3236
Mailing Address - Country:US
Mailing Address - Phone:512-321-8664
Mailing Address - Fax:
Practice Address - Street 1:6500 E 2ND ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4338
Practice Address - Country:US
Practice Address - Phone:307-577-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8369A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1780912246OtherBC/BS
WYW23404Medicare PIN