Provider Demographics
NPI:1700025285
Name:MEDINA, MARY BETH E (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MARY BETH
Middle Name:E
Last Name:MEDINA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13776 SWISS LANE, TRUCKEE, CA, USA
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE CA
Mailing Address - State:CA
Mailing Address - Zip Code:96161-3416
Mailing Address - Country:US
Mailing Address - Phone:510-367-5383
Mailing Address - Fax:510-367-5383
Practice Address - Street 1:2303 S VIRGINIA ST STE &
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-3416
Practice Address - Country:US
Practice Address - Phone:510-367-5383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-06
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA450481163WG0000X
CA18684363LF0000X
NV826254363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV826254OtherNV APRN LIC
14603059OtherCAQH
NVMM2111386OtherDEA