Provider Demographics
NPI:1417553967
Name:PENA, CHRISTIAN DAVID
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:DAVID
Last Name:PENA
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 1:84 GLEN HOLLOW DRIVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3511
Mailing Address - Country:US
Mailing Address - Phone:914-218-0040
Mailing Address - Fax:
Practice Address - Street 1:63 OAKCREST AVE
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-1415
Practice Address - Country:US
Practice Address - Phone:631-594-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2025-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012087225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant