Provider Demographics
NPI:1588852099
Name:MINNEAR, NINA M (PT)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:M
Last Name:MINNEAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1405 MILL ST
Mailing Address - Street 2:THEDACARE MEDICAL CENTER NEW LONDON
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2155
Mailing Address - Country:US
Mailing Address - Phone:920-531-2031
Mailing Address - Fax:920-531-2056
Practice Address - Street 1:1405 MILL ST
Practice Address - Street 2:THEDACARE MEDICAL CENTER NEW LONDON
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2155
Practice Address - Country:US
Practice Address - Phone:920-531-2031
Practice Address - Fax:920-531-2056
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI10457-024225100000X
IL070.014662225100000X
CO9897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61370258Medicaid