Provider Demographics
NPI:1730296013
Name:MEDINA, DIANA JEANNETTE (RPT)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:JEANNETTE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 E WALNUT ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-1619
Mailing Address - Country:US
Mailing Address - Phone:626-683-9959
Mailing Address - Fax:626-683-9969
Practice Address - Street 1:1650 E WALNUT ST
Practice Address - Street 2:STE A
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1619
Practice Address - Country:US
Practice Address - Phone:626-683-9959
Practice Address - Fax:626-683-9969
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19514225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT19514AMedicare PIN