Provider Demographics
NPI:1992580997
Name:MEDINA, MARISSA VERONICA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:VERONICA
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 1:3842 N 68TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2010
Mailing Address - Country:US
Mailing Address - Phone:414-499-7363
Mailing Address - Fax:
Practice Address - Street 1:3842 N 68TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2010
Practice Address - Country:US
Practice Address - Phone:414-499-7363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver