Provider Demographics
NPI:1356869325
Name:MEDINA, JESSE RAMONE (CRNA)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:RAMONE
Last Name:MEDINA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 N SHAWANO DR
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-1350
Mailing Address - Country:US
Mailing Address - Phone:956-579-5081
Mailing Address - Fax:
Practice Address - Street 1:1000 N OAK AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-5703
Practice Address - Country:US
Practice Address - Phone:715-387-5511
Practice Address - Fax:715-387-5240
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4012936367500000X
WI9050-33367500000X
TN32989367500000X
TX770560367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300086098Medicaid
KY7100952770Medicaid