Provider Demographics
NPI:1245342732
Name:MEDINA, DAVID MARK (PA-C)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MARK
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:155 SOLANO ST
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:CA
Mailing Address - Zip Code:96021-3511
Mailing Address - Country:US
Mailing Address - Phone:530-824-4663
Mailing Address - Fax:
Practice Address - Street 1:155 SOLANO ST
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:CA
Practice Address - Zip Code:96021-3511
Practice Address - Country:US
Practice Address - Phone:530-824-4663
Practice Address - Fax:530-824-5204
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17932363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ45197Medicare UPIN