Provider Demographics
NPI:1871013417
Name:PEQUENO, GARION
Entity Type:Individual
Prefix:
First Name:GARION
Middle Name:
Last Name:PEQUENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1947 E EL PARQUE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-2901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14 FARENHOLT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-0001
Practice Address - Country:US
Practice Address - Phone:619-532-7968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-25
Last Update Date:2017-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman