Provider Demographics
NPI:1285315135
Name:MEDINA, GUSTAVO A
Entity type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:A
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8275 S EASTERN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-2545
Mailing Address - Country:US
Mailing Address - Phone:435-229-3245
Mailing Address - Fax:
Practice Address - Street 1:8275 SOUTH EASTERN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PARADISE
Practice Address - State:NV
Practice Address - Zip Code:89123
Practice Address - Country:US
Practice Address - Phone:435-229-3245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator