Provider Demographics
NPI:1811977457
Name:MEDRANO, MITAS MOINA BALBIN
Entity type:Individual
Prefix:
First Name:MITAS MOINA
Middle Name:BALBIN
Last Name:MEDRANO
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MITAS MOINA
Other - Middle Name:BALBIN
Other - Last Name:FLORES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20508 W DANIEL PL
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-3649
Mailing Address - Country:US
Mailing Address - Phone:650-580-3503
Mailing Address - Fax:623-776-2813
Practice Address - Street 1:20508 W DANIEL PL
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85396-3649
Practice Address - Country:US
Practice Address - Phone:650-580-3503
Practice Address - Fax:623-776-2813
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7029225100000X
CA23719225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ335861Medicaid