MEDICARE: ALEXANDER PENA PA-C, ATC

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	363AM0700X	Medical Physician Assistant	PA9113666	FL

General Provider Information

NPI Number	:	1477937936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDER PENA PA-C, ATC

Provider Business Mailing Address
First Line	:	4580 RACE TRACK RD STE 102
Second Line	:
City	:	ST JOHNS
State	:	FL
Zip	:	32259-2457
Country	:	US
Telephone Number	:	904-679-3537
Fax Number	:	904-481-8651

Provider Business Practice Location Address
First Line	:	1677 WELLS RD STE C
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-2383
Country	:	US
Telephone Number	:	904-215-8400
Fax Number	:

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

Provider Enumeration Date	:	07/15/2015
Last Update Date	:	02/13/2026

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