Provider Demographics
NPI:1710196217
Name:MEDINA, GEORGIA
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20TH AVE MEDICAL OFFICES
Mailing Address - Street 2:2045 FRANKLIN STREET
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-4562
Mailing Address - Country:US
Mailing Address - Phone:303-764-8485
Mailing Address - Fax:
Practice Address - Street 1:2045 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5437
Practice Address - Country:US
Practice Address - Phone:303-764-8485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30865163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse