Provider Demographics
NPI:1285190991
Name:WIBERG, MATTHEW S
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:WIBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 W WACO DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-7010
Mailing Address - Country:US
Mailing Address - Phone:972-598-5894
Mailing Address - Fax:
Practice Address - Street 1:4300 W WACO DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-7010
Practice Address - Country:US
Practice Address - Phone:972-598-5894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic