Provider Demographics
NPI:1457317414
Name:MINE, MICHAEL J (CRNP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:MINE
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 KAUF RD
Mailing Address - Street 2:
Mailing Address - City:WEST SUNBURY
Mailing Address - State:PA
Mailing Address - Zip Code:16061-1720
Mailing Address - Country:US
Mailing Address - Phone:724-894-2327
Mailing Address - Fax:
Practice Address - Street 1:20630 ROUTE 19
Practice Address - Street 2:SUITE 101
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066
Practice Address - Country:US
Practice Address - Phone:724-779-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP000156A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily