Provider Demographics
NPI:1639587439
Name:MEDINA, MELISSA (NP-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35629
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-0629
Mailing Address - Country:US
Mailing Address - Phone:214-424-2200
Mailing Address - Fax:214-231-2159
Practice Address - Street 1:621 CAMDEN ST
Practice Address - Street 2:STE 202
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1612
Practice Address - Country:US
Practice Address - Phone:210-253-3422
Practice Address - Fax:210-227-9833
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126071363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01733200OtherRAILROAD MEDICARE
TX359783301Medicaid
TX8953NTOtherBLUE CROSS BLUE SHIELD
TX8953NTOtherBLUE CROSS BLUE SHIELD