Provider Demographics
NPI:1851606347
Name:MEDES, NINA (RPT)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:MEDES
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 1:38091 HIGH RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-8071
Mailing Address - Country:US
Mailing Address - Phone:909-740-4828
Mailing Address - Fax:
Practice Address - Street 1:38091 HIGH RIDGE DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-8071
Practice Address - Country:US
Practice Address - Phone:909-740-4828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36097208100000X
CO9849208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation