Provider Demographics
NPI:1942219803
Name:MEDINA, JONATHON DOMINIQUE (MD)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:DOMINIQUE
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 BLUEGRASS CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7364
Mailing Address - Country:US
Mailing Address - Phone:307-778-2577
Mailing Address - Fax:307-635-2131
Practice Address - Street 1:1950 BLUEGRASS CIR STE 200
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7364
Practice Address - Country:US
Practice Address - Phone:307-778-2577
Practice Address - Fax:307-635-2131
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43517207Q00000X
WY7156A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01727541Medicaid
CO803262Medicare ID - Type Unspecified
CO01727541Medicaid