Healthcare Provider Details

I. General information

NPI: 1033357942
Provider Name (Legal Business Name): LAURA MEDINA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 07/05/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 JEFFERSON ST NE
ALBUQUERQUE NM
87109-2136
US

IV. Provider business mailing address

1311A N MILDRED RD
CORTEZ CO
81321-2231
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-7464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34874
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD2016-0284
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: