Healthcare Provider Details

I. General information

NPI: 1780548917
Provider Name (Legal Business Name): ANDREA HERNANDEZ MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

726 E EDISON AVE
WILLIAMS AZ
86046-2120
US

V. Phone/Fax

Practice location:
  • Phone: 928-310-9400
  • Fax:
Mailing address:
  • Phone: 928-310-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number258776
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: