Healthcare Provider Details

I. General information

NPI: 1720040371
Provider Name (Legal Business Name): PHILLIP A MEDINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4361 TALBOT ROAD S #102
RENTON WA
98055
US

IV. Provider business mailing address

4361 TALBOT ROAD S #102
RENTON WA
98055
US

V. Phone/Fax

Practice location:
  • Phone: 425-226-1180
  • Fax: 425-235-0695
Mailing address:
  • Phone: 425-226-1180
  • Fax: 425-235-0695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD00028329
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: