Provider Demographics
NPI:1063852085
Name:MINADAKIS, DIMITRIOS N (PA-C)
Entity Type:Individual
Prefix:
First Name:DIMITRIOS
Middle Name:N
Last Name:MINADAKIS
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 1:16 JANICE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02664-2935
Mailing Address - Country:US
Mailing Address - Phone:320-291-3184
Mailing Address - Fax:320-291-3184
Practice Address - Street 1:495 STATION AVE
Practice Address - Street 2:
Practice Address - City:SOUTH YARMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02664-1218
Practice Address - Country:US
Practice Address - Phone:774-552-3208
Practice Address - Fax:320-202-8949
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1916363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1063852085Medicaid
MN970006940Medicare PIN