Provider Demographics
NPI:1770074106
Name:MEDINA, EDGAR JESUS (LPT)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:JESUS
Last Name:MEDINA
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 E PACIFIC COAST HWY STE 305
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-6960
Mailing Address - Country:US
Mailing Address - Phone:562-537-4225
Mailing Address - Fax:
Practice Address - Street 1:4510 E PACIFIC COAST HWY STE 305
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-6960
Practice Address - Country:US
Practice Address - Phone:562-537-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32653167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician