Provider Demographics
NPI:1679089213
Name:MINAHAN, JOHN R (CSRS I, EMT-B)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:MINAHAN
Suffix:
Gender:M
Credentials:CSRS I, EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PORTSMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:STRATHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03885-6528
Mailing Address - Country:US
Mailing Address - Phone:603-583-5119
Mailing Address - Fax:
Practice Address - Street 1:20 PORTSMOUTH AVE
Practice Address - Street 2:
Practice Address - City:STRATHAM
Practice Address - State:NH
Practice Address - Zip Code:03885-6528
Practice Address - Country:US
Practice Address - Phone:603-583-5119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNA204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine