Provider Demographics
NPI:1992324941
Name:MINIER, RYAN JORDAN (PA-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JORDAN
Last Name:MINIER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 BLOOMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-2101
Mailing Address - Country:US
Mailing Address - Phone:217-356-1558
Mailing Address - Fax:
Practice Address - Street 1:117 W PATERSON ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-2581
Practice Address - Country:US
Practice Address - Phone:269-349-2641
Practice Address - Fax:269-349-2898
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007716363A00000X
MI5601011654363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant