Provider Demographics
NPI:1912464488
Name:MOYD, MATTHEW ALEXANDER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ALEXANDER
Last Name:MOYD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7516 W OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53219-2860
Mailing Address - Country:US
Mailing Address - Phone:414-885-0456
Mailing Address - Fax:
Practice Address - Street 1:7516 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53219-2860
Practice Address - Country:US
Practice Address - Phone:414-885-0456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4578-23363A00000X
NY022892-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1912464488Medicaid