Provider Demographics
NPI:1811503055
Name:MORALES, MATTHEW VINCENT I
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:VINCENT
Last Name:MORALES
Suffix:I
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 1:9414 MOONBEAM AVE UNIT 15
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-1354
Mailing Address - Country:US
Mailing Address - Phone:626-716-6792
Mailing Address - Fax:
Practice Address - Street 1:4955 VAN NUYS BLVD STE 615
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1839
Practice Address - Country:US
Practice Address - Phone:626-716-6792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
60904363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program