Healthcare Provider Details

I. General information

NPI: 1295209229
Provider Name (Legal Business Name): SUSANA PENA SALAZAR SA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2019
Last Update Date: 02/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12507 COVE LANDING DR
CYPRESS TX
77433-3082
US

IV. Provider business mailing address

12507 COVE LANDING DR
CYPRESS TX
77433-3082
US

V. Phone/Fax

Practice location:
  • Phone: 832-769-7815
  • Fax:
Mailing address:
  • Phone: 832-769-7815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number18-504
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: