Provider Demographics
NPI:1558486985
Name:PENA, STEPHANIE MARIE MADORE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE MADORE
Last Name:PENA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 RICH ST APT A
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-3693
Mailing Address - Country:US
Mailing Address - Phone:617-721-4671
Mailing Address - Fax:
Practice Address - Street 1:67 UNION ST
Practice Address - Street 2:SUITE 308
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-7700
Practice Address - Country:US
Practice Address - Phone:508-655-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAP2050363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMA-AP2561OtherPROVIDER ID NUMBER
MAMA-AP2561OtherPROVIDER ID NUMBER