Provider Demographics
NPI:1770577397
Name:MEDINA, JOHN RAYMOND (PT)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RAYMOND
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1358
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28714-1358
Mailing Address - Country:US
Mailing Address - Phone:828-682-1500
Mailing Address - Fax:828-682-1505
Practice Address - Street 1:1720 W US HIGHWAY 19E
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28714-8602
Practice Address - Country:US
Practice Address - Phone:828-682-1500
Practice Address - Fax:828-682-1505
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC350866700OtherUS DEPT OF LABOR
NC58457OtherBLUE CROSS BLUE SHIELD
NC7210872Medicaid
NC65002114OtherMEDICARE RAILROAD
NCMEDCOSTOtherMEDCOST
NC64-0006OtherUNITED HEALTHCARE
NC7210872Medicaid