Provider Demographics
NPI:1073309563
Name:MEDINA, MICHAEL S
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:MEDINA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2994 MUD HOUSE RD NE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-8784
Mailing Address - Country:US
Mailing Address - Phone:719-641-6043
Mailing Address - Fax:
Practice Address - Street 1:2994 MUD HOUSE RD NE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-8784
Practice Address - Country:US
Practice Address - Phone:719-641-6043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-19
Last Update Date:2025-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker