Provider Demographics
NPI:1043923659
Name:KANTAREVIC, MEDINA
Entity Type:Individual
Prefix:
First Name:MEDINA
Middle Name:
Last Name:KANTAREVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 MAYNARD AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-1839
Mailing Address - Country:US
Mailing Address - Phone:319-529-8077
Mailing Address - Fax:
Practice Address - Street 1:1127 MAYNARD AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-1839
Practice Address - Country:US
Practice Address - Phone:319-529-8077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH171780363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner