MEDICARE: WILLIAM D PENNER COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	2505	NM

General Provider Information

NPI Number	:	1366714917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM D PENNER COTA/L

Provider Business Mailing Address
First Line	:	3734 PIEDRAS NEGRAS DR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012-7671
Country	:	US
Telephone Number	:	575-642-0920
Fax Number	:

Provider Business Practice Location Address
First Line	:	3734 PIEDRAS NEGRAS DR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012-7671
Country	:	US
Telephone Number	:	575-642-0920
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2012
Last Update Date	:	01/29/2012

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