Healthcare Provider Details

I. General information

NPI: 1316515737
Provider Name (Legal Business Name): ANDY JONATHAN MINEMANN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2021
Last Update Date: 06/13/2021
Certification Date: 06/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 DEAN LAKES BLVD
SHAKOPEE MN
55379-2829
US

IV. Provider business mailing address

750 ADAMS ST S
SHAKOPEE MN
55379-2288
US

V. Phone/Fax

Practice location:
  • Phone: 612-416-1301
  • Fax:
Mailing address:
  • Phone: 442-226-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: