1639587439 NPI number — MELISSA MEDINA NP-C

Table of content: MELISSA MEDINA NP-C (NPI 1639587439)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639587439 NPI number — MELISSA MEDINA NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA
Provider First Name:
MELISSA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639587439
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 35629
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75235-0629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-424-2200
Provider Business Mailing Address Fax Number:
214-231-2159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 CAMDEN ST
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78215-1612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-253-3422
Provider Business Practice Location Address Fax Number:
210-227-9833
Provider Enumeration Date:
07/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP126071 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P01733200 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 359783301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8953NT . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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