Provider Demographics
NPI:1629696786
Name:PENA, INDHIRA Y (SA-C)
Entity Type:Individual
Prefix:
First Name:INDHIRA
Middle Name:Y
Last Name:PENA
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 COMMODORE DR APT 114
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33325-2676
Mailing Address - Country:US
Mailing Address - Phone:954-398-0347
Mailing Address - Fax:
Practice Address - Street 1:20 COMMODORE DR APT 114
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33325-2676
Practice Address - Country:US
Practice Address - Phone:954-398-0347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
19-361246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty