Provider Demographics
NPI:1710613179
Name:MEDINA, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
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 1:15680 SW 18TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-5814
Mailing Address - Country:US
Mailing Address - Phone:786-273-1882
Mailing Address - Fax:
Practice Address - Street 1:15680 SW 18TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-5814
Practice Address - Country:US
Practice Address - Phone:786-273-1882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11019893363LA2100X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health