Provider Demographics
NPI:1790431989
Name:PENA, JOHN LEE (DPT)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEE
Last Name:PENA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 FIR TREE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-5027
Mailing Address - Country:US
Mailing Address - Phone:817-366-5754
Mailing Address - Fax:
Practice Address - Street 1:709 N FM 1187 STE 500
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:TX
Practice Address - Zip Code:76008-4338
Practice Address - Country:US
Practice Address - Phone:817-366-5754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1291049225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist