Provider Demographics
NPI:1174392765
Name:MEDINA, MARIELLA
Entity type:Individual
Prefix:
First Name:MARIELLA
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 1:116 UNION PARK ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2495
Mailing Address - Country:US
Mailing Address - Phone:240-383-7552
Mailing Address - Fax:
Practice Address - Street 1:136 HARRISON AVE RM 510A
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1817
Practice Address - Country:US
Practice Address - Phone:617-636-0975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-25
Last Update Date:2023-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant