Basic Information
| Provider Information | |||||||||
| NPI: | 1245439157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAKABENTA | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | LANE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA21190 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911851190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144494800 | ||||||||
| FaxNumber: | 7144494956 | ||||||||
| Practice Location | |||||||||
| Address1: | 2720 N HARBOR BLVD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928352609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144496230 | ||||||||
| FaxNumber: | 7144491773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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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 | PA18214 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA18214 | 01 | CA | LICENSE | OTHER |