Provider Demographics
NPI:1881772861
Name:MINGLE, RONALD MAX (PAC)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:MAX
Last Name:MINGLE
Suffix:
Gender:M
Credentials:PAC
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 994
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-0994
Mailing Address - Country:US
Mailing Address - Phone:989-463-0104
Mailing Address - Fax:989-463-0663
Practice Address - Street 1:1621 E BROOMFIELD ST
Practice Address - Street 2:SUITE B
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-5427
Practice Address - Country:US
Practice Address - Phone:989-772-1442
Practice Address - Fax:989-772-0735
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0853713260OtherBCBSM
MIR65840Medicare UPIN
MIP13710002Medicare PIN
B47935Medicare UPIN