Provider Demographics
NPI:1235198417
Name:HERNDON, MATTHEW B (PA C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:B
Last Name:HERNDON
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 FRANKLIN ST SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-4306
Mailing Address - Country:US
Mailing Address - Phone:256-539-2728
Mailing Address - Fax:256-428-3423
Practice Address - Street 1:927 FRANKLIN ST SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4306
Practice Address - Country:US
Practice Address - Phone:256-539-2728
Practice Address - Fax:256-428-3423
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA396363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0900180OtherUNITED HEALTHCARE
AL51000085OtherBCBS
AL009978295Medicaid
AL7346659OtherAETNA
AL$$$$$$$$$OtherTRICARE
Q28236Medicare UPIN
AL51000085OtherBCBS