Basic Information
| Provider Information | |||||||||
| NPI: | 1982641163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINEHART | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 855 N WESTHAVEN DR | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203038700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 855 N WESTHAVEN DR | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203038700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 06/22/2018 | ||||||||
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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 | 367500000X | 054040 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2130123001 | 01 | WI | UHC MA DIAMOND PROV # | OTHER | 54040 | 01 | WI | STATE LICENSE # | OTHER | P00141683 | 01 | WI | NETWORK HEALTH PROV # | OTHER | 44352600 | 05 | WI | MEDICAID |