Provider Demographics
NPI:1518314764
Name:MINNOE, PENNY LOU (PRESIDENT)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:LOU
Last Name:MINNOE
Suffix:
Gender:F
Credentials:PRESIDENT
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:GILFUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SECRETARY
Mailing Address - Street 1:1540 GRAY RD
Mailing Address - Street 2:
Mailing Address - City:UNION SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:13160-4100
Mailing Address - Country:US
Mailing Address - Phone:315-237-2814
Mailing Address - Fax:315-253-3166
Practice Address - Street 1:1597 CLARK STREET RD.
Practice Address - Street 2:C6
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13022
Practice Address - Country:US
Practice Address - Phone:315-237-2814
Practice Address - Fax:315-253-3166
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY300585673OtherTAX ID
NY03056420Medicaid