Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NN0400X | Neurology | 111NN0400X | NY |
Y | 213ES0103X | Foot & Ankle Surgery | 213E00000X | NY |
NPI | 1255733523 |
---|---|
Provider Name | Mr. Juan Pena |
First Address | Bronx, NY 10453-6323 |
Second Address | Bronx, NY 10453-6323 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/09/2014 |
Last Update Date | 18/09/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
SUPER1626 | (05) | NY |