Provider Demographics
NPI:1447651690
Name:BALANDA, MATTHEW L (APRN)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:L
Last Name:BALANDA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1389 W MAIN ST STE 205
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3115
Mailing Address - Country:US
Mailing Address - Phone:203-755-7080
Mailing Address - Fax:203-346-6244
Practice Address - Street 1:1389 W MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3115
Practice Address - Country:US
Practice Address - Phone:203-755-7080
Practice Address - Fax:203-346-6244
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5850363LF0000X, 363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008057928Medicaid
CT1356318091Medicaid