Healthcare Provider Details

I. General information

NPI: 1912563826
Provider Name (Legal Business Name): PENG MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 DAMONTE RANCH PKWY STE 1030
RENO NV
89521-5968
US

IV. Provider business mailing address

500 DAMONTE RANCH PKWY STE 1030
RENO NV
89521-5968
US

V. Phone/Fax

Practice location:
  • Phone: 775-432-6189
  • Fax: 775-284-5625
Mailing address:
  • Phone: 775-432-6189
  • Fax: 775-284-5625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HSIAOLIN FANG
Title or Position: PRACTICE MANAGER
Credential:
Phone: 217-299-5892