Provider Demographics
NPI:1205474160
Name:HERRON, MATTHEW GELSTON
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GELSTON
Last Name:HERRON
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 1:700 SHOSHONE AVE UNIT 26
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-5558
Mailing Address - Country:US
Mailing Address - Phone:307-922-1551
Mailing Address - Fax:
Practice Address - Street 1:700 SHOSHONE AVE UNIT 26
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-5558
Practice Address - Country:US
Practice Address - Phone:307-922-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator