Healthcare Provider Details

I. General information

NPI: 1396759569
Provider Name (Legal Business Name): JUN MANALO HERRERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NEMESIO M. HERRERA JR. MD

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 SIXTH AVENUE NORTH
ST CLOUD MN
56303-1901
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 612-262-1166
  • Fax:
Mailing address:
  • Phone:
  • Fax: 320-656-7115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number43953
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: