Healthcare Provider Details

I. General information

NPI: 1033546932
Provider Name (Legal Business Name): ANDREA CAROL PENA R.T. (R)
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2013
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12033 AGENCY RD
PARKER AZ
85344-7718
US

IV. Provider business mailing address

12033 AGENCY RD
PARKER AZ
85344-7718
US

V. Phone/Fax

Practice location:
  • Phone: 928-669-3380
  • Fax: 928-669-3377
Mailing address:
  • Phone: 928-669-3380
  • Fax: 928-669-3377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number13424
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: