Provider Demographics
NPI:1114310612
Name:MEDINA, ANASTACIA (PTA)
Entity Type:Individual
Prefix:
First Name:ANASTACIA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 BRIAR HOLLOW LN UNIT 401
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-9307
Mailing Address - Country:US
Mailing Address - Phone:281-513-3636
Mailing Address - Fax:
Practice Address - Street 1:1214 N POST OAK RD STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-7236
Practice Address - Country:US
Practice Address - Phone:713-880-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2061140172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker