=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548515919
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW DONALD MINER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2012
-----------------------------------------------------
Last Update Date | 12/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1104 GRUNDMAN BLVD
-----------------------------------------------------
City | NEBRASKA CITY
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68410-3397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-873-7411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2030 RAINBOW AVE
-----------------------------------------------------
City | SEWARD
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68434-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-643-0711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | NE3106
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------