Provider Demographics
NPI:1023052099
Name:MEDINA, MARK ALLEN (PTA10)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PTA10
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3471 S KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-3654
Mailing Address - Country:US
Mailing Address - Phone:414-486-1307
Mailing Address - Fax:
Practice Address - Street 1:3471 S KANSAS AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-3654
Practice Address - Country:US
Practice Address - Phone:414-486-1307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0848-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant