Provider Demographics
NPI:1841248507
Name:MINOR, INGRID (PA-C)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:MINOR
Suffix:
Gender:F
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:PO BOX 545
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-0545
Mailing Address - Country:US
Mailing Address - Phone:606-528-7400
Mailing Address - Fax:606-528-7449
Practice Address - Street 1:110 ROY KIDD AVE
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-1302
Practice Address - Country:US
Practice Address - Phone:606-528-7400
Practice Address - Fax:606-528-7449
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000605852OtherANTHEM
KY95004826Medicaid
KYQ24668Medicare UPIN
KY0764806Medicare PIN