Provider Demographics
NPI:1457481517
Name:PENA, RUBEN R (PA)
Entity Type:Individual
Prefix:MR
First Name:RUBEN
Middle Name:R
Last Name:PENA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 743752
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3752
Mailing Address - Country:US
Mailing Address - Phone:702-476-2800
Mailing Address - Fax:702-476-2040
Practice Address - Street 1:10652 S EASTERN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4952
Practice Address - Country:US
Practice Address - Phone:702-476-2800
Practice Address - Fax:702-476-2040
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601002738363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M28430133Medicare PIN
MIP75333Medicare UPIN