Healthcare Provider Details

I. General information

NPI: 1760661060
Provider Name (Legal Business Name): DR. NANCY PENG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2007
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 CARLOS ST # 206
MOSS BEACH CA
94038-9666
US

IV. Provider business mailing address

2315 CARLOS ST # 206
MOSS BEACH CA
94038-9666
US

V. Phone/Fax

Practice location:
  • Phone: 650-409-7030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT13276
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: