Healthcare Provider Details

I. General information

NPI: 1003664525
Provider Name (Legal Business Name): HERBERT MATANGA CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19427 136TH AVE N
ROGERS MN
55374-4834
US

IV. Provider business mailing address

19427 136TH AVE N
ROGERS MN
55374-4834
US

V. Phone/Fax

Practice location:
  • Phone: 763-516-4476
  • Fax:
Mailing address:
  • Phone: 763-516-4476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number11557
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: