Healthcare Provider Details

I. General information

NPI: 1639103278
Provider Name (Legal Business Name): PATRICIA MEDINA R.D. C.D.E.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 AVE HOSTOS MOPC VETERANS OUTPATIENT CLINIC
MAYAGUEZ PR
00680-1507
US

IV. Provider business mailing address

ESTANCIAS DEL PARRA #127
LAJAS PR
00667
US

V. Phone/Fax

Practice location:
  • Phone: 787-834-6900
  • Fax: 787-265-8809
Mailing address:
  • Phone: 787-473-8292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number436406
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: