Provider Demographics
NPI:1720372790
Name:MEDINA, ASHLEY MARIE CLARK (PA-C)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE CLARK
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PA-C
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 96822
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28296-6822
Mailing Address - Country:US
Mailing Address - Phone:800-889-4447
Mailing Address - Fax:
Practice Address - Street 1:3010 TRENWEST DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3208
Practice Address - Country:US
Practice Address - Phone:336-970-5300
Practice Address - Fax:336-970-6334
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-040992085R0204X, 363A00000X
FLPA9106003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY08KYOtherBLUE CROSS BLUE SHIELD
AL133176Medicaid
NC1720372790Medicaid
VA30018289480001Medicaid
NC188P0OtherBCBS