Provider Demographics
NPI:1740498559
Name:MEDINA, EMMANUEL (1666P)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:1666P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BUZON 899 16
Mailing Address - Street 2:BO CORAZON
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00784
Mailing Address - Country:US
Mailing Address - Phone:787-866-4436
Mailing Address - Fax:
Practice Address - Street 1:BARRIADA MARIN CALLE 5 NUMERO 29A
Practice Address - Street 2:
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:787-866-4436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRTC AMB 5223416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport