Provider Demographics
NPI:1437682705
Name:MEDINA, ROBERT (LAT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 WESTOVER AVE
Mailing Address - Street 2:APT 301
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-2313
Mailing Address - Country:US
Mailing Address - Phone:847-902-9786
Mailing Address - Fax:
Practice Address - Street 1:4500 PARKER AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23529-0001
Practice Address - Country:US
Practice Address - Phone:847-902-9786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260026562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer