Provider Demographics
NPI:1821209305
Name:PENA, PATRICIA (FNP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 E HERNDON AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3307
Mailing Address - Country:US
Mailing Address - Phone:559-438-3000
Mailing Address - Fax:559-439-0300
Practice Address - Street 1:720 E SAN BRUNO AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-7029
Practice Address - Country:US
Practice Address - Phone:559-341-7156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA428963363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA428963OtherRN LICENSE