Provider Demographics
NPI:1972643534
Name:MEDINA, JOSE (PA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:4300 W MEMORIAL RD
Practice Address - Street 2:ER DEPT
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8304
Practice Address - Country:US
Practice Address - Phone:405-752-3733
Practice Address - Fax:405-749-4557
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2014-05-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK1575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200105850AMedicaid
OK249713801Medicare PIN
OK249713802Medicare PIN
OKP00470356Medicare PIN