Provider Demographics
NPI:1811549835
Name:MEDINA, ANDREW G
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:G
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-6905
Mailing Address - Country:US
Mailing Address - Phone:866-727-8274
Mailing Address - Fax:
Practice Address - Street 1:4525 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-6905
Practice Address - Country:US
Practice Address - Phone:866-727-8274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician