Provider Demographics
NPI:1841431087
Name:MEDINA, JOSE MIGUEL (CRNA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MIGUEL
Last Name:MEDINA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 NOVUS DR STE 2
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-8237
Mailing Address - Country:US
Mailing Address - Phone:423-283-0776
Mailing Address - Fax:423-283-0549
Practice Address - Street 1:1009 NOVUS DR STE 2
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-8237
Practice Address - Country:US
Practice Address - Phone:423-283-0776
Practice Address - Fax:423-283-0549
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14033363LF0000X
SC26564367500000X
TNAPN14033367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN3780Medicaid
TN1532093Medicaid