Provider Demographics
NPI:1639111586
Name:MEDRANO, MIGUEL L (PA)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:L
Last Name:MEDRANO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 MEMORIAL ST
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-1524
Mailing Address - Country:US
Mailing Address - Phone:509-786-2222
Mailing Address - Fax:509-786-6612
Practice Address - Street 1:701 DALE AVE
Practice Address - Street 2:
Practice Address - City:BENTON CITY
Practice Address - State:WA
Practice Address - Zip Code:99320-5250
Practice Address - Country:US
Practice Address - Phone:509-588-4075
Practice Address - Fax:509-588-4197
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16427363A00000X
WAOA60464236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant