Healthcare Provider Details

I. General information

NPI: 1750177168
Provider Name (Legal Business Name): ANA LAURA NOYOLA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVE
MODESTO CA
95350-4404
US

IV. Provider business mailing address

533 ISLA VISTA TER
SUNNYVALE CA
94085-3786
US

V. Phone/Fax

Practice location:
  • Phone: 209-578-1211
  • Fax:
Mailing address:
  • Phone: 909-749-4853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA66530
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: