Provider Demographics
NPI:1811974082
Name:PENA, WILLIAM RODOLFO (PT DPT)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RODOLFO
Last Name:PENA
Suffix:
Gender:M
Credentials:PT DPT
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Mailing Address - Street 1:19 HODSKIN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1175
Mailing Address - Country:US
Mailing Address - Phone:315-379-0992
Mailing Address - Fax:315-379-0993
Practice Address - Street 1:19 HODSKIN ST
Practice Address - Street 2:STE 1
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1175
Practice Address - Country:US
Practice Address - Phone:315-379-0992
Practice Address - Fax:315-379-0993
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2019-09-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY0166341225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02163660Medicaid
RA1321Medicare ID - Type Unspecified