Provider Demographics
NPI:1477937936
Name:PENA, ALEXANDER (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1677 WELLS RD STE C
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2383
Mailing Address - Country:US
Mailing Address - Phone:904-215-8400
Mailing Address - Fax:904-215-8489
Practice Address - Street 1:1677 WELLS RD STE C
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-2383
Practice Address - Country:US
Practice Address - Phone:904-215-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL41952255A2300X
FLPA9113666363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer