Provider Demographics
NPI:1235734716
Name:MEDINA, RICHARD HIWATIG (DNP)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:HIWATIG
Last Name:MEDINA
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4144 HIGHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3617
Mailing Address - Country:US
Mailing Address - Phone:904-910-5414
Mailing Address - Fax:
Practice Address - Street 1:4144 HIGHWOOD DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-3617
Practice Address - Country:US
Practice Address - Phone:904-910-5414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9314274163W00000X
FLAPRN11011175367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse