Basic Information
| Provider Information | |||||||||
| NPI: | 1245377480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINKIN | ||||||||
| FirstName: | EDITH | ||||||||
| MiddleName: | SUSAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 WEBSTER ST | ||||||||
| Address2: | STE 8 | ||||||||
| City: | HANOVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023391227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817546545 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 WEBSTER ST | ||||||||
| Address2: | STE 8 | ||||||||
| City: | HANOVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023391227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817546545 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 149267 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 110091463A | 05 | MA | MEDICAID |