Provider Demographics
NPI:1578673976
Name:PENA, SARA R (MD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:R
Last Name:PENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3202 E GREENWAY RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4548
Mailing Address - Country:US
Mailing Address - Phone:602-325-5577
Mailing Address - Fax:
Practice Address - Street 1:3202 E GREENWAY RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4548
Practice Address - Country:US
Practice Address - Phone:602-325-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30236207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ716235Medicaid
AZ77883Medicare ID - Type UnspecifiedMEDICARE #