Provider Demographics
NPI:1316931322
Name:MEDINA, MARJORIE BURRY (CRNA)
Entity type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:BURRY
Last Name:MEDINA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 W WOODMERE RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3842
Mailing Address - Country:US
Mailing Address - Phone:813-600-7395
Mailing Address - Fax:
Practice Address - Street 1:4204 W WOODMERE RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3842
Practice Address - Country:US
Practice Address - Phone:813-600-7395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9243538367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038633000Medicaid
FLG4317OtherBCBS
FLG4317OtherBCBS