MEDICARE: MR. JOHN JOE PENA PA-C

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	1063193	TX

General Provider Information

NPI Number	:	1700885373
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN JOE PENA PA-C

Provider Business Mailing Address
First Line	:	1520 BRIARWYCK DR
Second Line	:
City	:	BROWNSVILLE
State	:	TX
Zip	:	78520-9275
Country	:	US
Telephone Number	:	512-608-1518
Fax Number	:	706-544-1113

Provider Business Practice Location Address
First Line	:	7950 MARTIN LOOP
Second Line	:
City	:	FORT BENNING
State	:	GA
Zip	:	31905-5647
Country	:	US
Telephone Number	:	706-544-1833
Fax Number	:

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

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	02/28/2015

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