Provider Demographics
NPI:1679629661
Name:MEDINA, VIOLA G (ARNP)
Entity Type:Individual
Prefix:
First Name:VIOLA
Middle Name:G
Last Name:MEDINA
Suffix:
Gender:F
Credentials:ARNP
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 2940
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-2940
Mailing Address - Country:US
Mailing Address - Phone:360-979-0569
Mailing Address - Fax:877-805-9505
Practice Address - Street 1:19980 10TH AVE NE STE 202
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6322
Practice Address - Country:US
Practice Address - Phone:360-979-0569
Practice Address - Fax:877-805-9505
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004058363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0039581OtherLABOR AND INDUSTRIES #
WA9619594Medicaid
WA0359072OtherLNI
WAUS2510511OtherAETNA SPECIALIST PIN
WA7793MEOtherBLUE SHIELD #
WA500017809OtherRAILROAD MC#
WAUS2510511OtherAETNA SPECIALIST PIN
WAAB21246Medicare PIN
P15142Medicare UPIN