=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609304070
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY RAY MEDINA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2017
-----------------------------------------------------
Last Update Date | 04/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 N 18TH ST STE C
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98273-3902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-424-6161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8100 CAMBRIDGE ST APT 131
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77054-3164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-230-2066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | MD61282818
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | BP10060352
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------