Healthcare Provider Details

I. General information

NPI: 1417792367
Provider Name (Legal Business Name): BRYIANE PASCUA MEDINA FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 ROCK QUARRY RD
RALEIGH NC
27610-3825
US

IV. Provider business mailing address

1011 ROCK QUARRY RD
RALEIGH NC
27610-3825
US

V. Phone/Fax

Practice location:
  • Phone: 919-833-3111
  • Fax: 202-555-0156
Mailing address:
  • Phone: 919-833-3111
  • Fax: 202-555-0156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5021146
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: