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General NPI Number Information
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NPI Number | 1811977457
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Entity Type | Individual
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Provider Name | MITAS MOINA BALBIN MEDRANO
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Gender | Female
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Dates
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Enumeration Date | 01/19/2006
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Last Update Date | 04/13/2017
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Provider Practice Location Address
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Address Line | 20508 W DANIEL PL
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City | BUCKEYE
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State | AZ
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Zip | 85396-3649
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Country | US
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Telephone | 650-580-3503
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Fax | 623-776-2813
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Provider Business Mailing Address
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Address Line | 20508 W DANIEL PL
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City | BUCKEYE
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State | AZ
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Zip | 85396-3649
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Country | US
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Telephone | 650-580-3503
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Fax | 623-776-2813
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 7029
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 23719
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License Number State | CA
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