Provider Demographics
NPI:1235448168
Name:QUEEN, MATTHEW SCOTT (MS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SCOTT
Last Name:QUEEN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5852
Mailing Address - Country:US
Mailing Address - Phone:208-419-9810
Mailing Address - Fax:
Practice Address - Street 1:2325 FIELDSTONE DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83401-5852
Practice Address - Country:US
Practice Address - Phone:208-419-9810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator