Provider Demographics
NPI:1649241464
Name:PENA, KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
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:PO BOX 1413
Mailing Address - Street 2:
Mailing Address - City:WELLFLEET
Mailing Address - State:MA
Mailing Address - Zip Code:02667-1413
Mailing Address - Country:US
Mailing Address - Phone:508-905-2800
Mailing Address - Fax:508-240-1244
Practice Address - Street 1:269 CHATHAM RD
Practice Address - Street 2:
Practice Address - City:HARWICH
Practice Address - State:MA
Practice Address - Zip Code:02645-3309
Practice Address - Country:US
Practice Address - Phone:508-432-1400
Practice Address - Fax:508-430-2333
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA82127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MACMSP 23523Medicaid
MAG22350Medicare UPIN
MAA20996Medicare ID - Type Unspecified