Provider Demographics
NPI:1164823464
Name:MEDINA, MAYREL
Entity type:Individual
Prefix:
First Name:MAYREL
Middle Name:
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 1:8425 NW 165TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6137
Mailing Address - Country:US
Mailing Address - Phone:786-357-3765
Mailing Address - Fax:786-431-5891
Practice Address - Street 1:1840 W 49TH ST STE 225
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2949
Practice Address - Country:US
Practice Address - Phone:786-536-4399
Practice Address - Fax:786-431-5891
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-06
Last Update Date:2014-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA24178225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA24178OtherAPT