Provider Demographics
NPI:1982496360
Name:MEDINA, RUDY
Entity type:Individual
Prefix:
First Name:RUDY
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31408 CLEMENT ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-5105
Mailing Address - Country:US
Mailing Address - Phone:714-225-3314
Mailing Address - Fax:
Practice Address - Street 1:31408 CLEMENT ST
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-5105
Practice Address - Country:US
Practice Address - Phone:714-225-3314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-21
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical