Provider Demographics
NPI:1609201540
Name:PENAHERRERA, PATRICIO
Entity Type:Individual
Prefix:
First Name:PATRICIO
Middle Name:
Last Name:PENAHERRERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 E LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-2221
Mailing Address - Country:US
Mailing Address - Phone:516-330-8723
Mailing Address - Fax:
Practice Address - Street 1:89440 OLD KEENE MILL ROAD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22301
Practice Address - Country:US
Practice Address - Phone:703-569-1300
Practice Address - Fax:703-569-1972
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program