Provider Demographics
NPI:1104907773
Name:MINNIX, TAMARA S (CRNA)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:S
Last Name:MINNIX
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 714960
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-4960
Mailing Address - Country:US
Mailing Address - Phone:888-245-5525
Mailing Address - Fax:717-653-8197
Practice Address - Street 1:1340 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3800
Practice Address - Country:US
Practice Address - Phone:888-245-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV41769367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0068794000Medicaid
KY74430216Medicaid
OH0892851Medicaid
WV001720975OtherBCBS
WV1067623OtherWORKERS' COMP
KY74430216Medicaid
WV8213893Medicare PIN
WV001720975OtherBCBS