Provider Demographics
NPI:1447232640
Name:MEDINA, MIGUEL ANGEL (PAC)
Entity Type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:ANGEL
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 E. SECOND STREET
Mailing Address - Street 2:SUITE 5
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-2007
Mailing Address - Country:US
Mailing Address - Phone:909-865-2565
Mailing Address - Fax:909-865-2955
Practice Address - Street 1:795 E SECOND ST.
Practice Address - Street 2:SUITE 5
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-2007
Practice Address - Country:US
Practice Address - Phone:909-865-2565
Practice Address - Fax:909-865-2955
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10383363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA10383Medicaid
CAPA10383Medicaid
P20913Medicare UPIN