Provider Demographics
NPI:1700397650
Name:MINOR, LARRY LAWAYNE (FNP)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:LAWAYNE
Last Name:MINOR
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:LAWAYNE
Other - Last Name:MINOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:4169 E CHOLLA CANYON DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6712
Mailing Address - Country:US
Mailing Address - Phone:480-495-5940
Mailing Address - Fax:
Practice Address - Street 1:4169 E CHOLLA CANYON DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6712
Practice Address - Country:US
Practice Address - Phone:480-495-5940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2017-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10495363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty