Provider Demographics
NPI:1225570450
Name:MEDINA, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
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:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-0204
Mailing Address - Country:US
Mailing Address - Phone:307-214-3115
Mailing Address - Fax:
Practice Address - Street 1:909 CR 159
Practice Address - Street 2:
Practice Address - City:PINE BLUFFS
Practice Address - State:WY
Practice Address - Zip Code:82082
Practice Address - Country:US
Practice Address - Phone:307-214-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician