Provider Demographics
NPI:1003664525
Name:MATANGA, HERBERT (CNP)
Entity type:Individual
Prefix:
First Name:HERBERT
Middle Name:
Last Name:MATANGA
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19427 136TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-4834
Mailing Address - Country:US
Mailing Address - Phone:763-516-4476
Mailing Address - Fax:
Practice Address - Street 1:19427 136TH AVE N
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4834
Practice Address - Country:US
Practice Address - Phone:763-516-4476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11557364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent