Healthcare Provider Details

I. General information

NPI: 1184824377
Provider Name (Legal Business Name): ANTONIO PENA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 12/02/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 STATE ST
ERIE PA
16550-0002
US

IV. Provider business mailing address

201 STATE ST
ERIE PA
16550-0002
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-6182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD442745
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: