Provider Demographics
NPI:1336198787
Name:PENA, SANDRA (CRNA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751730
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1730
Mailing Address - Country:US
Mailing Address - Phone:336-716-5599
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-5599
Practice Address - Fax:336-716-3202
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC055258367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNAN518Medicaid
NC8052054Medicaid
NC8052054Medicaid