Basic Information
Provider Information
NPI: 1003002486
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MINNER
FirstName: MEGAN
MiddleName: KATHLEEN
NamePrefix: MS.
NameSuffix:  
Credential: DC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4245 OLD HIGHWAY 100
Address2:  
City: WASHINGTON
State: MO
PostalCode: 630905714
CountryCode: US
TelephoneNumber: 3145701952
FaxNumber:  
Practice Location
Address1: 902 E 6TH ST
Address2: STE B
City: WASHINGTON
State: MO
PostalCode: 630905714
CountryCode: US
TelephoneNumber: 6362399997
FaxNumber: 6362399931
Other Information
ProviderEnumerationDate: 09/19/2007
LastUpdateDate: 06/20/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
111N00000X2007027755MOY Chiropractic ProvidersChiropractor 

ID Information
IDTypeStateIssuerDescription
110065201MOCIGNA PINOTHER
905810701MOAETNA PINOTHER
71417701MOUNITED HEALTHCARE PINOTHER
261152778MIN01MOMERCY PINOTHER


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