Healthcare Provider Details

I. General information

NPI: 1649858721
Provider Name (Legal Business Name): MATTHEW BRYCE ROBERTS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 PETERSEN PKWY
THAYNE WY
83127-9755
US

IV. Provider business mailing address

901 ADAMS ST
AFTON WY
83110-9621
US

V. Phone/Fax

Practice location:
  • Phone: 307-883-5852
  • Fax: 866-972-4881
Mailing address:
  • Phone: 307-885-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTL8316
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: