Provider Demographics
NPI:1043027352
Name:LOUIS MEDINA, BENJAMIN (CRNA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:LOUIS MEDINA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 BROOKDALE LN UNIT 7
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-4186
Mailing Address - Country:US
Mailing Address - Phone:207-975-0076
Mailing Address - Fax:
Practice Address - Street 1:405 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-7538
Practice Address - Country:US
Practice Address - Phone:937-723-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME152607367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered