Healthcare Provider Details

I. General information

NPI: 1154176550
Provider Name (Legal Business Name): REY GIOVANNI PEREZ MEDINA FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2024
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7219 N LITCHFIELD RD
LUKE AIR FORCE BASE AZ
85309-1529
US

IV. Provider business mailing address

7219 N LITCHFIELD RD
LUKE AIR FORCE BASE AZ
85309-1529
US

V. Phone/Fax

Practice location:
  • Phone: 623-856-6121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0999658-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: