Basic Information
| Provider Information | |||||||||
| NPI: | 1396009981 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANCOCK | ||||||||
| FirstName: | MINNA | ||||||||
| MiddleName: | LAUREN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 LANSING ST | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130211983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155670455 | ||||||||
| FaxNumber: | 3155670333 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 E GENESEE ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130214112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152527434 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2012 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 5101019747 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 295280 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 05427409 | 05 | NY | MEDICAID |