Provider Demographics
NPI:1558486985
Name:PENA, STEPHANIE M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:M
Last Name:PENA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 UNION STREET
Mailing Address - Street 2:SUITE 308
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760
Mailing Address - Country:US
Mailing Address - Phone:508-655-4422
Mailing Address - Fax:508-655-9191
Practice Address - Street 1:67 UNION STREET
Practice Address - Street 2:SUITE 308
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760
Practice Address - Country:US
Practice Address - Phone:508-655-4422
Practice Address - Fax:508-655-9191
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAP2050363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMA-AP2561OtherPROVIDER ID NUMBER
MAMA-AP2561OtherPROVIDER ID NUMBER