Provider Demographics
NPI:1033496930
Name:PENA, RUTH (PA-C)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
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 1:18270 SISKIYOU RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1413
Mailing Address - Country:US
Mailing Address - Phone:760-242-3677
Mailing Address - Fax:
Practice Address - Street 1:18270 SISKIYOU RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1413
Practice Address - Country:US
Practice Address - Phone:760-242-3677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-07
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21981363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical