| Brand Name | ACTIVA |
| Common Device Name | STIMULATOR, ELECTRICAL, IMPLANTED, FOR PARKINS |
| Manufacturer (Section D) |
| MEDTRONIC PUERTO RICO OPERATIONS CO. |
| road 31, km. 24, hm 4 |
| ceiba norte industrial park |
| juncos,pr MN 00777 |
|
| Manufacturer (Section G) |
| MEDTRONIC PUERTO RICO OPERATIONS CO. |
| road 31, km. 24, hm 4 |
| ceiba norte industrial park |
| juncos,pr MN 00777 |
|
| Manufacturer Contact |
|
justin
ellis
|
| 8200 coral sea street ne mvs21 |
| mounds view, MN 55112
|
|
7635265677
|
|
| MDR Report Key | 25058210 |
| Report Number | 2182207-2026-01152 |
| Device Sequence Number | 18667083 |
| Product Code |
MHY
|
| UDI-Device Identifier | 00763000384357 |
| UDI-Public | (01)00763000384357(17)211214 |
| Combination Product (Y/N) | N |
| Initial Reporter Country | US |
| PMA/510(K) Number | P960009 |
| Number of Events Summarized | 1 |
| Summary Report (Y/N) | N |
| Device Implanted Year | 2021 |
| Serviced by Third Party (Y/N) | N |
| Reporter Type |
Manufacturer
|
| Report Source |
Consumer |
| Initial Reporter Occupation |
Other
|
| Type of Report
| Initial,Followup |
| Report Date (Section B) |
05/19/2026 |
| 1 Device was Involved in the Event |
|
| 1 Patient was Involved in the Event |
|
| Is this an Adverse Event Report? |
No
|
| Is this a Product Problem Report? |
Yes
|
| Operator of Device |
Health Professional
|
| Device Expiration Date | 12/14/2021 |
| Device Model Number | 37612 |
| Device Catalogue Number | 37612 |
| Was Device Available for Evaluation? |
No
|
| Is the Reporter a Health Professional? |
No
|
| Type of Report(Section G) | Thirty-Day |
| Initial Date Received by Manufacturer | 04/06/2026 |
| Supplement Date Received by Manufacturer | 04/24/2026
|
| Initial Report FDA Received Date | 05/01/2026 |
| Supplement Report FDA Received Date | 05/19/2026
|
| Date Device Manufactured | 01/26/2021 |
| Is the Device Labeled for Single Use? (Y/N) |
Yes
|
Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N) |
No
|
| Usage of Device |
Initial
|
| Patient Sequence Number | 1 |
| Patient Sex | Male |
|
|