Provider Demographics
NPI:1194114827
Name:MINJAREZ, VINCENT ANDREW
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:ANDREW
Last Name:MINJAREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5863 OLEASTER DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79932-2338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1780 E UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88003-1229
Practice Address - Country:US
Practice Address - Phone:575-646-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-19
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2255A2300XOtherATHLETIC TRAINING TAXONOMY CODE
NM390200000XOtherSTUDENT TAXONOMY CODE