Healthcare Provider Details

I. General information

NPI: 1992324941
Provider Name (Legal Business Name): RYAN JORDAN MINIER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W PATERSON ST
KALAMAZOO MI
49007-2581
US

IV. Provider business mailing address

819 BLOOMINGTON RD
CHAMPAIGN IL
61820-2101
US

V. Phone/Fax

Practice location:
  • Phone: 269-349-2641
  • Fax: 269-349-2898
Mailing address:
  • Phone: 217-356-1558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007716
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011654
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: