Provider Demographics
NPI:1407834112
Name:MINEHAN, KIERNAN J (MD)
Entity Type:Individual
Prefix:
First Name:KIERNAN
Middle Name:J
Last Name:MINEHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1000
Mailing Address - Country:US
Mailing Address - Phone:920-746-0090
Mailing Address - Fax:920-746-1072
Practice Address - Street 1:3100 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1948
Practice Address - Country:US
Practice Address - Phone:920-451-7468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN322002085R0001X
WI446332085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN984365500Medicaid
MNP00055923Medicare ID - Type UnspecifiedRAILROAD
MN920000336Medicare PIN
E31780Medicare UPIN