Provider Demographics
NPI:1104013739
Name:MARISA C MEDINA MD PC
Entity Type:Organization
Organization Name:MARISA C MEDINA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARISA
Authorized Official - Middle Name:C
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-932-9824
Mailing Address - Street 1:11201 S EASTERN #120
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-6200
Mailing Address - Country:US
Mailing Address - Phone:702-731-9711
Mailing Address - Fax:702-731-0096
Practice Address - Street 1:11201 S EASTERN #120
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-6200
Practice Address - Country:US
Practice Address - Phone:702-731-9711
Practice Address - Fax:702-731-0096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVF67354Medicare UPIN
NVV36263Medicare PIN