Healthcare Provider Details

I. General information

NPI: 1336889559
Provider Name (Legal Business Name): ETHAN JAMES MATTHEW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6631 E 2ND ST STE 100
CASPER WY
82609-4355
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 307-243-1155
  • Fax: 307-243-1199
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number19102A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: