Healthcare Provider Details

I. General information

NPI: 1164589636
Provider Name (Legal Business Name): SANDRA ELAINE MEDINA MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDY MEDINA

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2719 N AIR FRESNO DR
FRESNO CA
93727-1547
US

IV. Provider business mailing address

1925 E DAKOTA AVE
FRESNO CA
93726-4821
US

V. Phone/Fax

Practice location:
  • Phone: 559-600-8918
  • Fax:
Mailing address:
  • Phone: 559-600-9180
  • Fax: 559-600-7905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: