1518413079 NPI number — MAYRENDY FABIOLA SEVERINO MEDINA

Table of content: MAYRENDY FABIOLA SEVERINO MEDINA (NPI 1518413079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518413079 NPI number — MAYRENDY FABIOLA SEVERINO MEDINA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEVERINO MEDINA
Provider First Name:
MAYRENDY
Provider Middle Name:
FABIOLA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1518413079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1405 JENEVEIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BRUNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94066-4132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 37TH AVE
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
SAN MATEO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94403-4324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-508-6745
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2016

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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