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General NPI Number Information
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NPI Number | 1700885373
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Entity Type | Individual
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Provider Name | JOHN JOE PENA PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/18/2005
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Last Update Date | 02/28/2015
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Provider Practice Location Address
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Address Line | 7950 MARTIN LOOP
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City | FORT BENNING
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State | GA
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Zip | 31905-5647
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Country | US
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Telephone | 706-544-1833
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Fax |
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Provider Business Mailing Address
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Address Line | 1520 BRIARWYCK DR
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City | BROWNSVILLE
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State | TX
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Zip | 78520-9275
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Country | US
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Telephone | 512-608-1518
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Fax | 706-544-1113
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 1063193
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License Number State | TX
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