Provider Demographics
NPI:1073093605
Name:MEDINA, JUAN CARLOS
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 HALE AVE
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-9300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3810 HALE AVE
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-9230
Practice Address - Country:US
Practice Address - Phone:956-412-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant