Healthcare Provider Details

I. General information

NPI: 1881772861
Provider Name (Legal Business Name): RONALD MAX MINGLE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 E BROOMFIELD ST SUITE B
MT PLEASANT MI
48858-5427
US

IV. Provider business mailing address

PO BOX 994
ALMA MI
48801-0994
US

V. Phone/Fax

Practice location:
  • Phone: 989-772-1442
  • Fax: 989-772-0735
Mailing address:
  • Phone: 989-463-0104
  • Fax: 989-463-0663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001143
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: