=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598059701
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDRIA P MEDINA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2011
-----------------------------------------------------
Last Update Date | 01/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4629 NW 23RD ST
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73127-2103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-251-8880
-----------------------------------------------------
Fax | 405-251-8881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 WOODMONT BLVD STE 600
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37205-5250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-314-5257
-----------------------------------------------------
Fax | 615-692-0547
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 28651
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 28651
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 28651
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------