Provider Demographics
NPI:1881827087
Name:MEDINA, COLLEEN ROSE
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:ROSE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 TIJERAS AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3099
Mailing Address - Country:US
Mailing Address - Phone:505-242-1010
Mailing Address - Fax:505-242-1551
Practice Address - Street 1:805 TIJERAS AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3099
Practice Address - Country:US
Practice Address - Phone:505-242-1010
Practice Address - Fax:505-242-1551
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator