Provider Demographics
NPI:1720040371
Name:MEDINA, PHILLIP A (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:A
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4361 TALBOT ROAD S
Mailing Address - Street 2:#102
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055
Mailing Address - Country:US
Mailing Address - Phone:425-226-1180
Mailing Address - Fax:425-235-0695
Practice Address - Street 1:4361 TALBOT ROAD S
Practice Address - Street 2:#102
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055
Practice Address - Country:US
Practice Address - Phone:425-226-1180
Practice Address - Fax:425-235-0695
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028329207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E74965Medicare UPIN
G000108467Medicare ID - Type Unspecified