Provider Demographics
NPI:1831478445
Name:MEDINA, NICHOLAS DEMECIO (ATC)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:DEMECIO
Last Name:MEDINA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7007 JEFFERSON ST NE STE C
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7007 JEFFERSON ST NE STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4450
Practice Address - Country:US
Practice Address - Phone:505-821-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM493171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor