Provider Demographics
NPI:1538540976
Name:MINICH, DARREN
Entity type:Individual
Prefix:
First Name:DARREN
Middle Name:
Last Name:MINICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:HANOVER TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18706-5478
Mailing Address - Country:US
Mailing Address - Phone:570-709-1960
Mailing Address - Fax:
Practice Address - Street 1:409 PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:HANOVER TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18706-5478
Practice Address - Country:US
Practice Address - Phone:570-709-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATPTA000367390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1Medicare PIN