Provider Demographics
NPI:1386767390
Name:MEDINA, ALONZO (MS)
Entity type:Individual
Prefix:
First Name:ALONZO
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2285
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004
Mailing Address - Country:US
Mailing Address - Phone:505-882-5101
Mailing Address - Fax:505-882-6127
Practice Address - Street 1:820 HWY 478
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021
Practice Address - Country:US
Practice Address - Phone:505-882-5101
Practice Address - Fax:505-882-6127
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator
Not Answered174400000XOther Service ProvidersSpecialist