Provider Demographics
NPI:1770582827
Name:MEDINA, ELSIE (PT)
Entity type:Individual
Prefix:
First Name:ELSIE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 467
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00954-0467
Mailing Address - Country:US
Mailing Address - Phone:787-870-8403
Mailing Address - Fax:787-870-8403
Practice Address - Street 1:URB. SANFERNANDO CALLE 1
Practice Address - Street 2:A1
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-870-8403
Practice Address - Fax:787-870-8403
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR856225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0020479Medicare ID - Type UnspecifiedNUMERO DE PROVEEDOR
PRP22489Medicare UPIN