Basic Information
| Provider Information | |||||||||
| NPI: | 1811970650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINNIE | ||||||||
| FirstName: | NICKOLAS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 MERCHANT ST | ||||||||
| Address2: | STE. 220 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452463700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135331199 | ||||||||
| FaxNumber: | 5136459787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3035 HAMILTON MASON RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138448585 | ||||||||
| FaxNumber: | 5138448769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2005 | ||||||||
| LastUpdateDate: | 02/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 36002464M | OH | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0795359 | 05 | OH | MEDICAID |