Basic Information
| Provider Information | |||||||||
| NPI: | 1679629661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | VIOLA | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2940 | ||||||||
| Address2: | |||||||||
| City: | POULSBO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983702940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609790569 | ||||||||
| FaxNumber: | 8778059505 | ||||||||
| Practice Location | |||||||||
| Address1: | 19980 10TH AVE NE STE 202 | ||||||||
| Address2: | |||||||||
| City: | POULSBO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983706322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609790569 | ||||||||
| FaxNumber: | 8778059505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP30004058 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0039581 | 01 | WA | LABOR AND INDUSTRIES # | OTHER | 9619594 | 05 | WA | MEDICAID | 0359072 | 01 | WA | LNI | OTHER | US2510511 | 01 | WA | AETNA SPECIALIST PIN | OTHER | 7793ME | 01 | WA | BLUE SHIELD # | OTHER | 500017809 | 01 | WA | RAILROAD MC# | OTHER |