Healthcare Provider Details

I. General information

NPI: 1932102829
Provider Name (Legal Business Name): KENNETH R MINK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 W 12TH ST
ERIE PA
16505-3380
US

IV. Provider business mailing address

3800 W 12TH ST
ERIE PA
16505-3380
US

V. Phone/Fax

Practice location:
  • Phone: 814-833-0399
  • Fax: 814-833-4999
Mailing address:
  • Phone: 814-833-0399
  • Fax: 814-833-4999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberMD054676L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: