Healthcare Provider Details

I. General information

NPI: 1437062015
Provider Name (Legal Business Name): EDGAR MEDINA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 KYLIE LN
SANTA ROSA CA
95409-7159
US

IV. Provider business mailing address

437 KYLIE LN
SANTA ROSA CA
95409-7159
US

V. Phone/Fax

Practice location:
  • Phone: 707-721-9956
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: