Provider Demographics
NPI:1164881983
Name:DELA PENA, RAY
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:DELA PENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2084
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-0084
Mailing Address - Country:US
Mailing Address - Phone:209-381-7879
Mailing Address - Fax:209-725-3775
Practice Address - Street 1:300 E 15TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6217
Practice Address - Country:US
Practice Address - Phone:209-381-6879
Practice Address - Fax:209-725-3775
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208911164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1013030808Medicaid
CA1013030808OtherMEDICAL