Healthcare Provider Details

I. General information

NPI: 1194653816
Provider Name (Legal Business Name): LIANA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E IDAHO AVE
LAS CRUCES NM
88001-4703
US

IV. Provider business mailing address

4320 BOGART LN
LAS CRUCES NM
88007-5507
US

V. Phone/Fax

Practice location:
  • Phone: 505-584-0134
  • Fax:
Mailing address:
  • Phone: 505-584-0134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number2061
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: