Provider Demographics
NPI:1811556756
Name:MEDINA VENTURA, MIGUEL A (RN)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
Last Name:MEDINA VENTURA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20309 FIELDTREE DR
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338-2344
Mailing Address - Country:US
Mailing Address - Phone:832-795-1305
Mailing Address - Fax:
Practice Address - Street 1:20309 FIELDTREE DR
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-2344
Practice Address - Country:US
Practice Address - Phone:832-795-1305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX908783163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR908783OtherREGISTERED NURSE