Healthcare Provider Details

I. General information

NPI: 1932883188
Provider Name (Legal Business Name): MADELENE PENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5308 N LOMBARD ST
PORTLAND OR
97203-4218
US

IV. Provider business mailing address

PO BOX 2908
PORTLAND OR
97208-2908
US

V. Phone/Fax

Practice location:
  • Phone: 888-227-5155
  • Fax: 971-282-0085
Mailing address:
  • Phone: 425-207-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA223183
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: