Basic Information
| Provider Information | |||||||||
| NPI: | 1093067514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENA | ||||||||
| FirstName: | YADIRA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, SUITE 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103291071 | ||||||||
| FaxNumber: | 4103291054 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W MAIN ST STE 116 | ||||||||
| Address2: | |||||||||
| City: | BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314226166 | ||||||||
| FaxNumber: | 6314226266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2012 | ||||||||
| LastUpdateDate: | 11/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 157231 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.