Provider Demographics
NPI:1417045444
Name:PENA, DANIEL (ATC, LPTA)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:ATC, LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7413 LUELLA ANNE DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3935
Mailing Address - Country:US
Mailing Address - Phone:505-872-2000
Mailing Address - Fax:
Practice Address - Street 1:4501 BIGGS AVENUE BLDG 939
Practice Address - Street 2:
Practice Address - City:KIRTLAND AFB
Practice Address - State:NM
Practice Address - Zip Code:87117-1908
Practice Address - Country:US
Practice Address - Phone:505-846-7377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-287225200000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
020802030OtherBOARD OF CERTIFICATON FOR ATHLETIC TRAINERS