Provider Demographics
NPI:1770869596
Name:MEDINA, MONIQUE CHERIE (PA)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:CHERIE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10710 CHARTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3260
Mailing Address - Country:US
Mailing Address - Phone:410-644-1880
Mailing Address - Fax:410-730-1617
Practice Address - Street 1:10710 CHARTER DR STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3260
Practice Address - Country:US
Practice Address - Phone:410-644-1880
Practice Address - Fax:410-730-1617
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2019-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004570363AM0700X
MDC04570363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD257075OtherJHHC
MD9253775OtherAETNA PPO
MD8367541OtherAETNA HMO
MD8367541OtherAETNA HMO