MEDICARE: MR. JEREMY CHRISTOPHER MINOR LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	267815-1	NY

General Provider Information

NPI Number	:	1609022987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEREMY CHRISTOPHER MINOR LPN

Provider Business Mailing Address
First Line	:	8 JAMES DORLAND DR
Second Line	:
City	:	WAPPINGERS FALLS
State	:	NY
Zip	:	12590-6432
Country	:	US
Telephone Number	:	845-797-6757
Fax Number	:	845-473-6692

Provider Business Practice Location Address
First Line	:	8 JAMES DORLAND DR
Second Line	:
City	:	WAPPINGERS FALLS
State	:	NY
Zip	:	12590-6432
Country	:	US
Telephone Number	:	845-797-6757
Fax Number	:	845-473-6692

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2008
Last Update Date	:	08/18/2008

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