Provider Demographics
NPI:1568943728
Name:MINARDI, MICHAEL DERRICK (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DERRICK
Last Name:MINARDI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 HIGHCROFT PL
Mailing Address - Street 2:
Mailing Address - City:WEATOGUE
Mailing Address - State:CT
Mailing Address - Zip Code:06089-7916
Mailing Address - Country:US
Mailing Address - Phone:970-948-7267
Mailing Address - Fax:
Practice Address - Street 1:538 LITCHFIELD ST STE 102
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6669
Practice Address - Country:US
Practice Address - Phone:860-496-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4206OtherPHYSICIAN ASSISTANT LICENSE