Provider Demographics
NPI:1275897704
Name:MINNIS, REGINALD EUGENE (PTA)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:EUGENE
Last Name:MINNIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4113 GARDEN BIRCH CV
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-6603
Mailing Address - Country:US
Mailing Address - Phone:901-600-4306
Mailing Address - Fax:
Practice Address - Street 1:4113 GARDEN BIRCH CV
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-6603
Practice Address - Country:US
Practice Address - Phone:901-600-4306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4622225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant