Healthcare Provider Details

I. General information

NPI: 1104149715
Provider Name (Legal Business Name): MATTHEW RAYMOND MINOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 PIPER ST STE A
ANCHORAGE AK
99508-4651
US

IV. Provider business mailing address

3650 PIPER ST STE A
ANCHORAGE AK
99508-4651
US

V. Phone/Fax

Practice location:
  • Phone: 907-339-9455
  • Fax: 907-339-9445
Mailing address:
  • Phone: 907-339-9455
  • Fax: 907-339-9445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number101175
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101250253
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: