Healthcare Provider Details

I. General information

NPI: 1952868044
Provider Name (Legal Business Name): JULIAN MEDINA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9708 RIVERSIDE CIR
ELLICOTT CITY MD
21042-5712
US

IV. Provider business mailing address

9708 RIVERSIDE CIR
ELLICOTT CITY MD
21042-5712
US

V. Phone/Fax

Practice location:
  • Phone: 410-688-7469
  • Fax:
Mailing address:
  • Phone: 410-688-7469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: