Provider Demographics
NPI:1942789367
Name:MEDRANO, JOEL PHILLIP
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:PHILLIP
Last Name:MEDRANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20508 W DANIEL PL
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-3649
Mailing Address - Country:US
Mailing Address - Phone:714-659-1969
Mailing Address - Fax:
Practice Address - Street 1:1665 N AVONDALE BLVD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5006
Practice Address - Country:US
Practice Address - Phone:602-933-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTAP11637363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty