Provider Demographics
NPI:1649858721
Name:ROBERTS, MATTHEW BRYCE (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRYCE
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-9621
Mailing Address - Country:US
Mailing Address - Phone:307-885-5800
Mailing Address - Fax:
Practice Address - Street 1:122 PETERSEN PKWY
Practice Address - Street 2:
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127-9755
Practice Address - Country:US
Practice Address - Phone:307-883-5852
Practice Address - Fax:866-972-4881
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL8316207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program