1376655829 NPI number — MR. FREDERICK GERALD MINER PA-C.

Table of content: MR. FREDERICK GERALD MINER PA-C. (NPI 1376655829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376655829 NPI number — MR. FREDERICK GERALD MINER PA-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MINER
Provider First Name:
FREDERICK
Provider Middle Name:
GERALD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376655829
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1035 116TH AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98004-4604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-688-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
GAMEDAY MENS HEALTH - SAN MARCOS
Provider Second Line Business Practice Location Address:
1340 WONDER WORLD DR, SUITE 104
Provider Business Practice Location Address City Name:
SAN MARCOS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
737-331-0301
Provider Business Practice Location Address Fax Number:
737-932-6224
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA10005213 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 119537500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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