Provider Demographics
NPI:1013355171
Name:MEDINA, AMY M
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
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 1:2530 CAMPBELLGATE DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3118
Mailing Address - Country:US
Mailing Address - Phone:248-709-7230
Mailing Address - Fax:
Practice Address - Street 1:2530 CAMPBELLGATE DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3118
Practice Address - Country:US
Practice Address - Phone:248-709-7230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor