Provider Demographics
NPI:1124366224
Name:PENA, JOHN PERCIVAL (ANP-BC, GNP, RN-BSN)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PERCIVAL
Last Name:PENA
Suffix:
Gender:M
Credentials:ANP-BC, GNP, RN-BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E 93RD ST APT 2D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-3980
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L LEVY PL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6500
Practice Address - Country:US
Practice Address - Phone:212-241-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306047-1363LA2200X
NYF340844-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology