Provider Demographics
NPI:1679178008
Name:MEDINA, DARA
Entity type:Individual
Prefix:MS
First Name:DARA
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 1:125 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-2406
Mailing Address - Country:US
Mailing Address - Phone:848-248-7215
Mailing Address - Fax:
Practice Address - Street 1:125 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:NJ
Practice Address - Zip Code:07747-2406
Practice Address - Country:US
Practice Address - Phone:848-248-7215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01083800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily