Provider Demographics
NPI:1629047881
Name:PENA, LEINI-LUCK (MD)
Entity Type:Individual
Prefix:
First Name:LEINI-LUCK
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3196 S MARYLAND PKWY
Mailing Address - Street 2:STE 101
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109
Mailing Address - Country:US
Mailing Address - Phone:702-731-8099
Mailing Address - Fax:702-731-8292
Practice Address - Street 1:3186 S MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109
Practice Address - Country:US
Practice Address - Phone:702-731-8099
Practice Address - Fax:702-731-8292
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10387207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018818Medicaid
AZ784448Medicaid
NV101100Medicare ID - Type Unspecified
AZ784448Medicaid