Provider Demographics
NPI:1417553967
Name:PENA, CHRISTIAN DAVID
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:DAVID
Last Name: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 1:17730 WEXFORD TER APT 703
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-2959
Mailing Address - Country:US
Mailing Address - Phone:914-218-0040
Mailing Address - Fax:
Practice Address - Street 1:17730 WEXFORD TER APT 703
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-2959
Practice Address - Country:US
Practice Address - Phone:914-218-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012087225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant