Provider Demographics
NPI:1245457738
Name:MEDINA, MODESTO (PA)
Entity type:Individual
Prefix:MR
First Name:MODESTO
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 HARWIN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-2097
Mailing Address - Country:US
Mailing Address - Phone:713-541-6988
Mailing Address - Fax:
Practice Address - Street 1:7447 HARWIN DR STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-2097
Practice Address - Country:US
Practice Address - Phone:713-541-6988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01382363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant