Provider Demographics
NPI:1134686462
Name:MEDINA, IRIS
Entity type:Individual
Prefix:
First Name:IRIS
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IRIS
Other - Middle Name:
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IRIS MEDINA
Mailing Address - Street 1:32 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-3307
Mailing Address - Country:US
Mailing Address - Phone:978-259-3305
Mailing Address - Fax:
Practice Address - Street 1:32 FOREST ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-3307
Practice Address - Country:US
Practice Address - Phone:978-259-3305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program