MEDICARE: MARIA TINA PENALOSA PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0110001786	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00271162	OTHER		TRAVELERS RR MEDICARE
5	C13214	OTHER		MEDICARE RR GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	541870984006	OTHER	CHAMPUS
4	10004736P	OTHER	SENTARA OPTIMA

General Provider Information

NPI Number	:	1083673586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA TINA PENALOSA PAC

Provider Business Mailing Address
First Line	:	6333 CENTER DR BLDG 16
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23502-4126
Country	:	US
Telephone Number	:	757-252-9500
Fax Number	:	757-962-9801

Provider Business Practice Location Address
First Line	:	6333 CENTER DR BLDG 16
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23502-4126
Country	:	US
Telephone Number	:	757-252-9500
Fax Number	:	757-962-9801

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	03/02/2022

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Directions to “ MARIA TINA PENALOSA PAC” Practice Location

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