Provider Demographics
NPI:1619942505
Name:MINICHAN, JOHN ALLEN (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALLEN
Last Name:MINICHAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0037
Mailing Address - Country:US
Mailing Address - Phone:316-281-3700
Mailing Address - Fax:316-282-4322
Practice Address - Street 1:2201 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101
Practice Address - Country:US
Practice Address - Phone:606-327-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2888A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2097734Medicaid
KY000000249239OtherANTHEM BLUE CROSS BLUE SHIELD
WV2604107000Medicaid
KY74028887Medicaid
KY000000249239OtherANTHEM BLUE CROSS BLUE SHIELD
KYP00164181Medicare PIN