Provider Demographics
NPI:1861696023
Name:MEDAMERICA
Entity type:Organization
Organization Name:MEDAMERICA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:ANNEMARIE
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:559-277-9892
Mailing Address - Street 1:5512 W OAK AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722
Mailing Address - Country:US
Mailing Address - Phone:559-917-8043
Mailing Address - Fax:
Practice Address - Street 1:2174 N ANTIOCH AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-7310
Practice Address - Country:US
Practice Address - Phone:559-277-9892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9936363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========8Medicare ID - Type Unspecified