Provider Demographics
NPI:1083673586
Name:PENALOSA, MARIA TINA (PAC)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:TINA
Last Name:PENALOSA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 CENTER DR BLDG 16
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4126
Mailing Address - Country:US
Mailing Address - Phone:757-252-9500
Mailing Address - Fax:757-962-9801
Practice Address - Street 1:6333 CENTER DR BLDG 16
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4126
Practice Address - Country:US
Practice Address - Phone:757-252-9500
Practice Address - Fax:757-962-9801
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
10245036OtherMEDICAID FIRST HEALTH
541870984006OtherCHAMPUS
P00271162OtherTRAVELERS RR MEDICARE
10004736POtherSENTARA OPTIMA
C13214OtherMEDICARE RR GROUP
C13214OtherMEDICARE RR GROUP
009223G25Medicare ID - Type UnspecifiedTRAILBLAZERS
C05825Medicare ID - Type UnspecifiedGROUP