1164589636 NPI number — SANDRA ELAINE MEDINA MS

Table of content: SANDRA ELAINE MEDINA MS (NPI 1164589636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164589636 NPI number — SANDRA ELAINE MEDINA MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA
Provider First Name:
SANDRA
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEDINA
Provider Other First Name:
SANDY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1164589636
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1925 E DAKOTA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93726-4821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-600-9180
Provider Business Mailing Address Fax Number:
559-600-7905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2719 N AIR FRESNO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93727-1547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-600-8918
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2007

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: 172V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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