Provider Demographics
NPI:1033115670
Name:MINTA, MICHELLE (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MINTA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29211
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9211
Mailing Address - Country:US
Mailing Address - Phone:602-273-6770
Mailing Address - Fax:602-889-0489
Practice Address - Street 1:4441 E MCDOWELL RD
Practice Address - Street 2:STE 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4503
Practice Address - Country:US
Practice Address - Phone:602-273-6770
Practice Address - Fax:602-889-0489
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN097097367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP76613Medicare UPIN
AZ101197Medicare ID - Type Unspecified