Provider Demographics
NPI:1144773953
Name:PENA, VALERIE ANNE (PAC)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:ANNE
Last Name:PENA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:VALERIE
Other - Middle Name:ANNE
Other - Last Name:CZEBOTAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:HEMATOLOGY AND ONCOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-9699
Mailing Address - Fax:414-805-2934
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:HEMATOLOGY AND ONCOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-9699
Practice Address - Fax:414-805-2934
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3848-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1144773953Medicaid