Basic Information
| Provider Information | |||||||||
| NPI: | 1467967240 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | MONIQUE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 SANDS PARC BLVD APT 412 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321170061 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 77 W GRANADA BLVD | ||||||||
| Address2: | |||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321746302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866770453 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2017 | ||||||||
| LastUpdateDate: | 12/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9110897 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.