Provider Demographics
NPI:1023069960
Name:MEDINA, TANYA M (MD)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:618 13TH ST
Mailing Address - Street 2:STEA
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-4503
Mailing Address - Country:US
Mailing Address - Phone:407-556-3999
Mailing Address - Fax:407-556-3933
Practice Address - Street 1:618 13TH ST
Practice Address - Street 2:STE A
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4503
Practice Address - Country:US
Practice Address - Phone:407-556-3999
Practice Address - Fax:407-556-3933
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME84474207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270733100Medicaid
50032ZMedicare UPIN
FLK7144Medicare UPIN
FLI25127Medicare UPIN