Provider Demographics
NPI:1396917480
Name:PENA, SAMUEL (PA)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:956-378-6611
Mailing Address - Fax:956-378-6070
Practice Address - Street 1:4302 S SUGAR RD STE 213
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-9140
Practice Address - Country:US
Practice Address - Phone:956-378-6611
Practice Address - Fax:956-378-6070
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA04603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3368243-02Medicaid