Provider Demographics
NPI:1649932344
Name:MINNICK, AUSTIN (PA-C)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:MINNICK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1495 WHITE ASH DR
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-5468
Mailing Address - Country:US
Mailing Address - Phone:440-227-7179
Mailing Address - Fax:
Practice Address - Street 1:2049 E 100TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-2104
Practice Address - Country:US
Practice Address - Phone:216-444-6126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-10
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007220RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical