Provider Demographics
NPI:1265828255
Name:MINTAH, CHAILLE
Entity Type:Individual
Prefix:
First Name:CHAILLE
Middle Name:
Last Name:MINTAH
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 1:120 HOBART ST
Mailing Address - Street 2:RESIDENCY PROGRAM
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4308
Mailing Address - Country:US
Mailing Address - Phone:315-801-1149
Mailing Address - Fax:315-801-3565
Practice Address - Street 1:120 HOBART ST
Practice Address - Street 2:RESIDENCY PROGRAM
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501
Practice Address - Country:US
Practice Address - Phone:315-801-1149
Practice Address - Fax:315-801-3565
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295435207P00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program