Healthcare Provider Details

I. General information

NPI: 1164274700
Provider Name (Legal Business Name): JOE MEDINA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 YALE BLVD SE
ALBUQUERQUE NM
87106-4273
US

IV. Provider business mailing address

2300 YALE BLVD SE
ALBUQUERQUE NM
87106-4273
US

V. Phone/Fax

Practice location:
  • Phone: 505-206-5643
  • Fax: 505-420-4855
Mailing address:
  • Phone: 505-206-5643
  • Fax: 505-420-4855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number1433
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: