Provider Demographics
NPI:1104873082
Name:MEDINA, DIANA (PA-C)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 GALISTEO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2101
Mailing Address - Country:US
Mailing Address - Phone:505-995-4901
Mailing Address - Fax:505-989-6426
Practice Address - Street 1:2025 GALISTEO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2101
Practice Address - Country:US
Practice Address - Phone:505-995-4901
Practice Address - Fax:505-989-6426
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-PA07363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
QMYPR0068422OtherMOLINA
201006707OtherPRESBYTERIAN HEALTH PLANS
NM98151Medicaid
NM98151Medicaid