Provider Demographics
NPI:1649476011
Name:MEDEIROS, DINA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:DINA
Middle Name:MARIE
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DINA
Other - Middle Name:M
Other - Last Name:MEDEIROS DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1264 HAWKS FLIGHT CT STE 100
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9354
Practice Address - Country:US
Practice Address - Phone:916-939-8400
Practice Address - Fax:916-939-8971
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA184490Medicare PIN