Provider Demographics
NPI:1356525091
Name:MEDINA, ROBERTO E (CCP)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:E
Last Name:MEDINA
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 SANDALWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-9627
Mailing Address - Country:US
Mailing Address - Phone:505-522-2418
Mailing Address - Fax:
Practice Address - Street 1:4604 SANDALWOOD DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-9627
Practice Address - Country:US
Practice Address - Phone:505-522-2418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPF0495242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist