Provider Demographics
NPI:1437690799
Name:MEDINA, JAIME
Entity Type:Individual
Prefix:
First Name:JAIME
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 1:68 E 11TH ST STE 115
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-4089
Mailing Address - Country:US
Mailing Address - Phone:209-666-7178
Mailing Address - Fax:
Practice Address - Street 1:68 E 11TH ST STE 115
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-4089
Practice Address - Country:US
Practice Address - Phone:209-666-7178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-19
Last Update Date:2017-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver