Provider Demographics
NPI:1235185190
Name:MEDINA, ROBERT M (PA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:M
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:390 NORTH LOOP ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-5109
Mailing Address - Country:US
Mailing Address - Phone:760-383-5289
Mailing Address - Fax:760-383-5128
Practice Address - Street 1:390 NORTH LOOP ROAD
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310-5109
Practice Address - Country:US
Practice Address - Phone:760-383-5289
Practice Address - Fax:760-383-5128
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29781ZMedicare ID - Type Unspecified
CAGR0050900Medicare ID - Type Unspecified