Provider Demographics
NPI:1174779177
Name:MEDINA, ANTHONY E
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:E
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 1:2696 LAWRENCEVILLE SUWANEE RD
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2535
Mailing Address - Country:US
Mailing Address - Phone:678-376-1300
Mailing Address - Fax:678-514-2936
Practice Address - Street 1:2696 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2535
Practice Address - Country:US
Practice Address - Phone:678-376-1300
Practice Address - Fax:678-514-2936
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC60035704101YM0800X
GA006030363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health