Provider Demographics
NPI:1578348868
Name:MEDINA, MELISSA (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8440 PARSONS BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1644
Mailing Address - Country:US
Mailing Address - Phone:917-803-5545
Mailing Address - Fax:
Practice Address - Street 1:9033 ELMHURST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7935
Practice Address - Country:US
Practice Address - Phone:718-565-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP124121225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant