Provider Demographics
NPI:1427763499
Name:MINGUS, ROBERT W (DRIVER)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:MINGUS
Suffix:
Gender:M
Credentials:DRIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 SHIRA RD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:ID
Mailing Address - Zip Code:83552-5044
Mailing Address - Country:US
Mailing Address - Phone:208-926-0894
Mailing Address - Fax:
Practice Address - Street 1:126 SHIRA RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:ID
Practice Address - Zip Code:83552-5044
Practice Address - Country:US
Practice Address - Phone:208-926-0894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDWA122376H347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle