Provider Demographics
NPI:1720302466
Name:MEDINA, JOSE (PA)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:81 WILLOUGHBY ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5291
Mailing Address - Country:US
Mailing Address - Phone:718-522-3399
Mailing Address - Fax:718-522-1888
Practice Address - Street 1:81 WILLOUGHBY ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5291
Practice Address - Country:US
Practice Address - Phone:718-522-3399
Practice Address - Fax:718-522-1888
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY6801300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6801300OtherLICENSE#