Provider Demographics
NPI:1174704597
Name:MINASYAN, VARTAN
Entity type:Individual
Prefix:
First Name:VARTAN
Middle Name:
Last Name:MINASYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11082 COLOMA RD
Mailing Address - Street 2:SUITE #10
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-2875
Mailing Address - Country:US
Mailing Address - Phone:916-638-2363
Mailing Address - Fax:916-638-2364
Practice Address - Street 1:11082 COLOMA RD
Practice Address - Street 2:SUITE #10
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-2875
Practice Address - Country:US
Practice Address - Phone:916-638-2363
Practice Address - Fax:916-638-2364
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101072332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1246540001Medicare NSC