Provider Demographics
NPI:1396759569
Name:HERRERA, JUN MANALO (MD)
Entity type:Individual
Prefix:MR
First Name:JUN
Middle Name:MANALO
Last Name:HERRERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:NEMESIO
Other - Middle Name:M
Other - Last Name:HERRERA
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:320-656-7115
Practice Address - Street 1:1406 SIXTH AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1901
Practice Address - Country:US
Practice Address - Phone:612-262-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43953208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN928151700Medicaid
MN250000926Medicare UPIN
H38811Medicare UPIN