Provider Demographics
NPI:1619622297
Name:MEDLIN, ANDREE JARED
Entity Type:Individual
Prefix:
First Name:ANDREE
Middle Name:JARED
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 1:431 MELBA ST APT 1409
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-4726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4941
Practice Address - Country:US
Practice Address - Phone:817-702-3431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-13
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1046713367500000X
FLAPRN11021318367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered