Provider Demographics
NPI:1366189540
Name:MEDINA, JOHANNA BEATRIZ (NP)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:BEATRIZ
Last Name:MEDINA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1243 BRETTON RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1421
Mailing Address - Country:US
Mailing Address - Phone:718-551-6297
Mailing Address - Fax:
Practice Address - Street 1:400 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3815
Practice Address - Country:US
Practice Address - Phone:516-472-5800
Practice Address - Fax:516-472-5805
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY349364204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery