Provider Demographics
NPI:1306043641
Name:MINOR, WILLIAM ANTHONY (IDC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ANTHONY
Last Name:MINOR
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 LOWER GAINSVILLE RD
Mailing Address - Street 2:SBT 22
Mailing Address - City:SSC
Mailing Address - State:MS
Mailing Address - Zip Code:39529
Mailing Address - Country:US
Mailing Address - Phone:228-813-4000
Mailing Address - Fax:
Practice Address - Street 1:2603 LOWER GAINSVILLE RD
Practice Address - Street 2:NATTC SBT 22
Practice Address - City:SSC
Practice Address - State:MS
Practice Address - Zip Code:39529
Practice Address - Country:US
Practice Address - Phone:228-813-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians