Provider Demographics
NPI:1699112524
Name:FIEBELKORN, MATTHEW WADE (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WADE
Last Name:FIEBELKORN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BORDEAUX CT
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1443
Mailing Address - Country:US
Mailing Address - Phone:651-717-8321
Mailing Address - Fax:
Practice Address - Street 1:1250 FRONTAGE RD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-2103
Practice Address - Country:US
Practice Address - Phone:651-717-8321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-01
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5807111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN46-2543934OtherTIN