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: | 1115 E 5TH ST | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | MO | ||||||||
PostalCode: | 630903303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6362399997 | ||||||||
FaxNumber: | 6362399931 | ||||||||
Practice Location | |||||||||
Address1: | 1115 E 5TH ST | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | MO | ||||||||
PostalCode: | 630903303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6362399997 | ||||||||
FaxNumber: | 6362399931 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2007 | ||||||||
LastUpdateDate: | 02/19/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 2007027755 | MO | Y |   | Chiropractic Providers | Chiropractor |   |
ID Information
ID | Type | State | Issuer | Description | 1100652 | 01 | MO | CIGNA PIN | OTHER | 261152778MIN | 01 | MO | MERCY PIN | OTHER | 714177 | 01 | MO | UNITED HEALTHCARE PIN | OTHER | 9058107 | 01 | MO | AETNA PIN | OTHER |