Basic Information
Provider Information | |||||||||
NPI: | 1861454415 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MEDINA | ||||||||
FirstName: | DEANNA | ||||||||
MiddleName: | SUE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR/L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PEKAREK | ||||||||
OtherFirstName: | DEANNA | ||||||||
OtherMiddleName: | SUE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OTR/L | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 88 NDG/SGHJ | ||||||||
Address2: | 4881 SUGAR MAPLE DR | ||||||||
City: | WRIGHT-PATTERSON AFB | ||||||||
State: | OH | ||||||||
PostalCode: | 45433 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372578718 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5955 ZEAMER AVE | ||||||||
Address2: | 673 MDOS/SGOY | ||||||||
City: | JBER | ||||||||
State: | AK | ||||||||
PostalCode: | 995063702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075801530 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2006 | ||||||||
LastUpdateDate: | 05/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 106340 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.