Provider Demographics
NPI:1003843293
Name:PENA, PATRICIA (DC)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4799 SUGARLOAF PKWY
Mailing Address - Street 2:STE L
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-8836
Mailing Address - Country:US
Mailing Address - Phone:770-513-1005
Mailing Address - Fax:770-513-0570
Practice Address - Street 1:4799 SUGARLOAF PKWY
Practice Address - Street 2:STE L
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-8836
Practice Address - Country:US
Practice Address - Phone:770-513-1005
Practice Address - Fax:770-513-0570
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006376111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCFWNMedicare PIN
GAU79091Medicare UPIN