Healthcare Provider Details

I. General information

NPI: 1952225740
Provider Name (Legal Business Name): MR. ANDREW MEDINA I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 BLOSSOM HILL RD STE 10
SAN JOSE CA
95124-6350
US

IV. Provider business mailing address

1604 BLOSSOM HILL RD STE 10
SAN JOSE CA
95124-6350
US

V. Phone/Fax

Practice location:
  • Phone: 408-528-8833
  • Fax: 408-827-4171
Mailing address:
  • Phone: 408-528-8833
  • Fax: 408-827-4171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number55083
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: