Provider Demographics
NPI:1114928363
Name:MINTON, GRETA SUE
Entity Type:Individual
Prefix:MRS
First Name:GRETA
Middle Name:SUE
Last Name:MINTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 S CHANCERY ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-3614
Mailing Address - Country:US
Mailing Address - Phone:931-668-2273
Mailing Address - Fax:931-815-2305
Practice Address - Street 1:2413 SOUTH CHANCERY STREET
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110
Practice Address - Country:UM
Practice Address - Phone:931-668-2273
Practice Address - Fax:931-815-2305
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN000005830363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3347391Medicaid
TNS59447Medicare UPIN
TN3347391Medicaid