Basic Information
| Provider Information | |||||||||
| NPI: | 1538624432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S NEVADA AVE | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702497751 | ||||||||
| FaxNumber: | 9702495029 | ||||||||
| Practice Location | |||||||||
| Address1: | 816 S 5TH ST STE B | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814015765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702493322 | ||||||||
| FaxNumber: | 9702407976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2019 | ||||||||
| LastUpdateDate: | 02/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0994430 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0994430 | 01 | CO | STATE LICENSE | OTHER |