Provider Demographics
NPI:1437418324
Name:HERMANSEN, MATTHEW DAVID (DO, PHARMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
Last Name:HERMANSEN
Suffix:
Gender:M
Credentials:DO, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6381 BOIS D'ARC
Mailing Address - Street 2:
Mailing Address - City:GILMER
Mailing Address - State:TX
Mailing Address - Zip Code:75644
Mailing Address - Country:US
Mailing Address - Phone:903-576-2594
Mailing Address - Fax:
Practice Address - Street 1:14700 28TH AVE N STE 20
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4876
Practice Address - Country:US
Practice Address - Phone:763-559-3779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46508183500000X
IN02005166A207L00000X
TXBP10046239390200000X
TXQ9372207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program