Provider Demographics
NPI:1730917311
Name:MEDINA, MIRKA M SR
Entity type:Individual
Prefix:MS
First Name:MIRKA
Middle Name:M
Last Name:MEDINA
Suffix:SR
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 1:1311 MAMARONECK AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-5222
Mailing Address - Country:US
Mailing Address - Phone:914-328-2868
Mailing Address - Fax:
Practice Address - Street 1:1311 MAMARONECK AVE STE 150
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-5222
Practice Address - Country:US
Practice Address - Phone:913-328-2868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist