Provider Demographics
NPI:1376865659
Name:PENG, MIAO QIN
Entity type:Individual
Prefix:DR
First Name:MIAO
Middle Name:QIN
Last Name:PENG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6708 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-4501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:451 RIDGEDALE AVE
Practice Address - Street 2:
Practice Address - City:EAST HANOVER
Practice Address - State:NJ
Practice Address - Zip Code:07936-1437
Practice Address - Country:US
Practice Address - Phone:973-463-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-27
Last Update Date:2010-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0533161183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist