Provider Demographics
NPI:1972496768
Name:MEDINA, LAURA SYDNEY
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:SYDNEY
Last Name:MEDINA
Suffix:
Gender:F
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 565
Mailing Address - Street 2:
Mailing Address - City:RIMFOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92378-0565
Mailing Address - Country:US
Mailing Address - Phone:909-800-4488
Mailing Address - Fax:
Practice Address - Street 1:27169 CA-189 SUITE 2
Practice Address - Street 2:
Practice Address - City:BLUE JAY
Practice Address - State:CA
Practice Address - Zip Code:92317
Practice Address - Country:US
Practice Address - Phone:909-855-0861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8171225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant