Provider Demographics
NPI:1659043453
Name:MEDINA, BERNARDO ANDRE (PTA)
Entity Type:Individual
Prefix:
First Name:BERNARDO
Middle Name:ANDRE
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 E VINSON AVE APT 5202
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-4044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2204 PEASE ST
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8308
Practice Address - Country:US
Practice Address - Phone:956-425-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2152874225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty