Basic Information
| Provider Information | |||||||||
| NPI: | 1558351460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | EDWARD | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1710 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811012302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195893658 | ||||||||
| FaxNumber: | 7195890997 | ||||||||
| Practice Location | |||||||||
| Address1: | 1710 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811012302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195893658 | ||||||||
| FaxNumber: | 7195890997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1115 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 840706945169 | 01 | CO | ROCKY MOUNTAIN HEALTH PLA | OTHER |