Provider Demographics
NPI:1558037275
Name:MEDINA, MIRIAM SORAYA (FNP)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:SORAYA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 PAEGLOW ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78235-1007
Mailing Address - Country:US
Mailing Address - Phone:210-324-1737
Mailing Address - Fax:
Practice Address - Street 1:4885 EL DORADO PKWY
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-8662
Practice Address - Country:US
Practice Address - Phone:972-464-5746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-22
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1051794363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily