Healthcare Provider Details

I. General information

NPI: 1679089213
Provider Name (Legal Business Name): JOHN R MINAHAN CSRS I, EMT-B
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PORTSMOUTH AVE
STRATHAM NH
03885-6528
US

IV. Provider business mailing address

20 PORTSMOUTH AVE
STRATHAM NH
03885-6528
US

V. Phone/Fax

Practice location:
  • Phone: 603-583-5119
  • Fax:
Mailing address:
  • Phone: 603-583-5119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberNA
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: