Provider Demographics
NPI:1154488146
Name:PENA, VAN ARTHUR (PHD, MD)
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:ARTHUR
Last Name:PENA
Suffix:
Gender:M
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6136 BATESOLE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-9504
Mailing Address - Country:US
Mailing Address - Phone:707-542-8107
Mailing Address - Fax:707-542-8107
Practice Address - Street 1:6136 BATESOLE DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-9504
Practice Address - Country:US
Practice Address - Phone:707-542-8107
Practice Address - Fax:707-542-8107
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA47927Medicare UPIN