Provider Demographics
NPI:1801536784
Name:MEDINA, MICHAEL ALEXANDER (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALEXANDER
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E VALENCIA MESA DR STE 310
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3800
Mailing Address - Country:US
Mailing Address - Phone:714-734-3120
Mailing Address - Fax:
Practice Address - Street 1:100 E VALENCIA MESA DR STE 310
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3800
Practice Address - Country:US
Practice Address - Phone:714-734-3120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61254363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant