Provider Demographics
NPI:1407651086
Name:MEDINA, ISAIAS
Entity type:Individual
Prefix:
First Name:ISAIAS
Middle Name:
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:PO BOX 3590
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-0071
Mailing Address - Country:US
Mailing Address - Phone:844-982-6374
Mailing Address - Fax:
Practice Address - Street 1:17130 SEQUOIA ST STE 104
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1827
Practice Address - Country:US
Practice Address - Phone:844-982-6374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker