Provider Demographics
NPI:1578188025
Name:MEDLIN, JOSEPH
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:MEDLIN
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 1:1855 W BASELINE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-9098
Mailing Address - Country:US
Mailing Address - Phone:480-238-6234
Mailing Address - Fax:
Practice Address - Street 1:915 N 52ND ST APT 2010
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-7934
Practice Address - Country:US
Practice Address - Phone:480-238-6234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ242146363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health