Provider Demographics
NPI:1952468704
Name:MEDINA, PEGGY LEE
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:LEE
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 1:1539 NE F STREET
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526
Mailing Address - Country:US
Mailing Address - Phone:541-956-7647
Mailing Address - Fax:541-956-8739
Practice Address - Street 1:1539 NE F ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526
Practice Address - Country:US
Practice Address - Phone:541-956-7647
Practice Address - Fax:541-956-8739
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
5322880001Medicare ID - Type Unspecified