Provider Demographics
NPI:1881867224
Name:MEDINA-TANCO, ISRAEL (SW)
Entity Type:Individual
Prefix:MR
First Name:ISRAEL
Middle Name:
Last Name:MEDINA-TANCO
Suffix:
Gender:M
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 AVE P DE LEON STOP 20
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-4022
Mailing Address - Country:US
Mailing Address - Phone:787-724-8585
Mailing Address - Fax:787-724-2520
Practice Address - Street 1:1406 AVE P DE LEON STOP 20
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-4022
Practice Address - Country:US
Practice Address - Phone:787-724-8585
Practice Address - Fax:787-724-2520
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3945104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker