Provider Demographics
NPI:1609802990
Name:SAN AGUSTIN-MEDINA, ANGELYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:ANGELYNN
Middle Name:
Last Name:SAN AGUSTIN-MEDINA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2590 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2619
Mailing Address - Country:US
Mailing Address - Phone:805-477-6464
Mailing Address - Fax:805-477-6498
Practice Address - Street 1:888 S HILL RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-8400
Practice Address - Country:US
Practice Address - Phone:805-477-6464
Practice Address - Fax:805-477-6498
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ51639Medicare UPIN