Provider Demographics
NPI:1720030083
Name:PENA, TERESA A (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:A
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 1:4525 WHITE BEAR PKWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7651
Mailing Address - Country:US
Mailing Address - Phone:651-564-4884
Mailing Address - Fax:
Practice Address - Street 1:4525 WHITE BEAR PKWY
Practice Address - Street 2:SUITE 130
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-7651
Practice Address - Country:US
Practice Address - Phone:651-564-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42447207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH09302Medicare UPIN