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 221249
Mailing Address - Street 2:MECKLENBURG RADIOLOGY ASSOCIATES
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28222-1249
Mailing Address - Country:US
Mailing Address - Phone:704-332-1291
Mailing Address - Fax:704-926-1832
Practice Address - Street 1:3623 LATROBE DR STE 216
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-332-1291
Practice Address - Fax:704-332-5206
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2020-09-29
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
FLFG391YMedicare PIN