Provider Demographics
NPI:1699823344
Name:MEDINA, MEGAN RENEE (NP)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:RENEE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1717 MAIN ST
Mailing Address - Street 2:SUITE 5200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4612
Mailing Address - Country:US
Mailing Address - Phone:214-712-2067
Mailing Address - Fax:214-712-2487
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5674
Practice Address - Country:US
Practice Address - Phone:979-297-4411
Practice Address - Fax:214-712-2487
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2008-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX648846363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
8Y1761OtherBCBSTX
8J7850Medicare PIN