Healthcare Provider Details

I. General information

NPI: 1174725766
Provider Name (Legal Business Name): YAMIL R. PENA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 KS HWY 264
LARNED KS
67550-5353
US

IV. Provider business mailing address

1301 KS HWY 264
LARNED KS
67550-5353
US

V. Phone/Fax

Practice location:
  • Phone: 620-285-4507
  • Fax: 620-285-4509
Mailing address:
  • Phone: 620-285-4507
  • Fax: 620-285-4509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberP48151
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: