Provider Demographics
NPI:1952956963
Name:MEDINA, ALBERTO SEGUNDO (PA)
Entity Type:Individual
Prefix:
First Name:ALBERTO
Middle Name:SEGUNDO
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:13407 N 25TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-1401
Mailing Address - Country:US
Mailing Address - Phone:407-427-5706
Mailing Address - Fax:
Practice Address - Street 1:521 W THOMAS RD FL 2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4241
Practice Address - Country:US
Practice Address - Phone:602-254-0390
Practice Address - Fax:888-846-8757
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001267-PA363A00000X
AZ9682363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant