Healthcare Provider Details

I. General information

NPI: 1205690534
Provider Name (Legal Business Name): KEVIN MEDINA CRUZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB FUENTE BELLA 1419 ST. ROMA
TOA ALTA PR
00953-3400
US

IV. Provider business mailing address

URB FUENTE BELLA 1419 ST. ROMA
TOA ALTA PR
00953-3400
US

V. Phone/Fax

Practice location:
  • Phone: 787-923-5015
  • Fax:
Mailing address:
  • Phone: 787-923-5015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number98018
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: