Provider Demographics
NPI:1366288961
Name:MINICK, CARSON DOUGLAS (PA-S)
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:DOUGLAS
Last Name:MINICK
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42ND AND EMILE ST 3225 S 44TH STREET OMAHA NE 68105
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-0001
Mailing Address - Country:US
Mailing Address - Phone:402-559-6673
Mailing Address - Fax:
Practice Address - Street 1:42ND AND EMILE ST 3225 S 44TH STREET OMAHA NE 68105
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-0001
Practice Address - Country:US
Practice Address - Phone:402-559-6673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0000000000207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services