Provider Demographics
NPI:1346675170
Name:PENA, BLANCA OLIVIA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:BLANCA
Middle Name:OLIVIA
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 1:2700 N 140TH AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2439
Mailing Address - Country:US
Mailing Address - Phone:623-535-8770
Mailing Address - Fax:623-535-8771
Practice Address - Street 1:2700 N 140TH AVE STE 107
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2439
Practice Address - Country:US
Practice Address - Phone:623-535-8770
Practice Address - Fax:623-535-8771
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2013-0061363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ080389Medicaid