Provider Demographics
NPI:1760472773
Name:DWYER, MINDA JOY (NP)
Entity Type:Individual
Prefix:MRS
First Name:MINDA
Middle Name:JOY
Last Name:DWYER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MINDA
Other - Middle Name:JOY
Other - Last Name:HUBBARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:66 HACKETT BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12209-1750
Mailing Address - Country:US
Mailing Address - Phone:518-262-4439
Mailing Address - Fax:518-262-8460
Practice Address - Street 1:66 HACKETT BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12209-1750
Practice Address - Country:US
Practice Address - Phone:518-262-4439
Practice Address - Fax:518-262-8460
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302093363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02053978Medicaid
NY02053978Medicaid
NYBB9988Medicare ID - Type Unspecified