Healthcare Provider Details

I. General information

NPI: 1922345495
Provider Name (Legal Business Name): MAYRA G PENA WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2013
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 COMMERCIAL AVE
SAN ANTONIO TX
78221-3117
US

IV. Provider business mailing address

3750 COMMERCIAL AVE
SAN ANTONIO TX
78221-3117
US

V. Phone/Fax

Practice location:
  • Phone: 210-922-7000
  • Fax: 210-923-6235
Mailing address:
  • Phone: 210-922-7000
  • Fax: 210-923-6235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number714925
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP123018
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: