Provider Demographics
NPI:1376599126
Name:PENA VARGAS, VERONICA (NP)
Entity Type:Individual
Prefix:MRS
First Name:VERONICA
Middle Name:
Last Name:PENA VARGAS
Suffix:
Gender:F
Credentials:NP
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 930
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970
Mailing Address - Country:US
Mailing Address - Phone:978-825-6591
Mailing Address - Fax:978-825-7070
Practice Address - Street 1:496 LYNNFIELD ST
Practice Address - Street 2:SUITE 201
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-1423
Practice Address - Country:US
Practice Address - Phone:781-593-3400
Practice Address - Fax:781-477-1187
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA198590363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0700169Medicaid
NP2059Medicare ID - Type Unspecified
MANP205902Medicare PIN
392250Medicare UPIN
MANP205903Medicare PIN