Basic Information
| Provider Information | |||||||||
| NPI: | 1902385453 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAIME MEDRANO MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S AIRPORT DR STE E | ||||||||
| Address2: | |||||||||
| City: | WESLACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785965396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9569735024 | ||||||||
| FaxNumber: | 9569735064 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 S AIRPORT DR STE E | ||||||||
| Address2: | |||||||||
| City: | WESLACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785965396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9569735024 | ||||||||
| FaxNumber: | 9569735064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2018 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | MEDRANO | ||||||||
| AuthorizedOfficialFirstName: | JAIME | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9569735024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1629035423 | 01 | NPI | OTHER | 03-7773102 | 05 | TX | MEDICAID | K1873 | 01 | TEXAS PHYSICIAN PERMIT | OTHER |