Provider Demographics
NPI:1164274700
Name:MEDINA, JOE
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:
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 1:203 CALIFORNIA ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1802
Mailing Address - Country:US
Mailing Address - Phone:505-239-0034
Mailing Address - Fax:
Practice Address - Street 1:203 CALIFORNIA ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1802
Practice Address - Country:US
Practice Address - Phone:505-308-8296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1433175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist