Healthcare Provider Details

I. General information

NPI: 1508684085
Provider Name (Legal Business Name): JULIA EMMA MEDINA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 BLACK ROCK AVE
BRIDGEPORT CT
06605-1200
US

IV. Provider business mailing address

PO BOX 552
RIVERSIDE CT
06878-0552
US

V. Phone/Fax

Practice location:
  • Phone: 203-579-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6849
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: