Provider Demographics
NPI:1588367312
Name:MEDINA, ALEXIS (DPT)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CRATER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731-9010
Mailing Address - Country:US
Mailing Address - Phone:908-907-4346
Mailing Address - Fax:
Practice Address - Street 1:2290 W COUNTY LINE RD STE 215
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-2267
Practice Address - Country:US
Practice Address - Phone:732-363-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02161500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist