Provider Demographics
NPI:1447408570
Name:PENA, CARLOS ERNESTO (PA)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ERNESTO
Last Name:PENA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 F. AVENUE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607
Mailing Address - Country:US
Mailing Address - Phone:520-364-1429
Mailing Address - Fax:520-364-4261
Practice Address - Street 1:100 E 5TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-2859
Practice Address - Country:US
Practice Address - Phone:520-364-7659
Practice Address - Fax:520-364-8541
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4229363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant