Provider Demographics
NPI:1821442609
Name:PENA, JONATHAN DELL PANGELINAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN DELL
Middle Name:PANGELINAN
Last Name:PENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MDG/SGOE
Mailing Address - Street 2:101 BODIN CIRCLE
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1800
Mailing Address - Country:US
Mailing Address - Phone:707-423-3825
Mailing Address - Fax:
Practice Address - Street 1:60 MDG/SGOE
Practice Address - Street 2:101 BODIN CIRCLE
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1800
Practice Address - Country:US
Practice Address - Phone:707-423-3825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA146279207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine