Provider Demographics
NPI:1013570118
Name:PENA, ERICA MARIA (PA-C)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:MARIA
Last Name:PENA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 ROXBORO CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5663
Mailing Address - Country:US
Mailing Address - Phone:678-353-5640
Mailing Address - Fax:
Practice Address - Street 1:6131 S NORCROSS TUCKER RD STE 6
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-5536
Practice Address - Country:US
Practice Address - Phone:678-205-1959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA38817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant