Provider Demographics
NPI:1164998167
Name:MINEMAN, MARY KATE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATE
Last Name:MINEMAN
Suffix:
Gender:F
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 1:18425 WEST CREEK DR
Mailing Address - Street 2:STEF
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2220
Mailing Address - Country:US
Mailing Address - Phone:708-209-6783
Mailing Address - Fax:
Practice Address - Street 1:18425 WEST CREEK DR
Practice Address - Street 2:STEF
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2220
Practice Address - Country:US
Practice Address - Phone:708-209-6783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant