Provider Demographics
NPI:1467173930
Name:MEDINA, MARK (RN)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1331
Mailing Address - Country:US
Mailing Address - Phone:719-248-5043
Mailing Address - Fax:
Practice Address - Street 1:1600 W 24TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-1411
Practice Address - Country:US
Practice Address - Phone:719-546-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1658172163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse