Provider Demographics
NPI:1093067514
Name:PENA, YADIRA (PA-C)
Entity Type:Individual
Prefix:
First Name:YADIRA
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 1:11350 MCCORMICK RD
Mailing Address - Street 2:EXECUTIVE PLAZA 1, SUITE 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031
Mailing Address - Country:US
Mailing Address - Phone:410-329-1071
Mailing Address - Fax:410-329-1054
Practice Address - Street 1:500 W MAIN ST STE 116
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702
Practice Address - Country:US
Practice Address - Phone:631-422-6166
Practice Address - Fax:631-422-6266
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY157231363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant