Basic Information
| Provider Information | |||||||||
| NPI: | 1366732604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 N MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882602830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753966611 | ||||||||
| FaxNumber: | 5753964547 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 N MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882602830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753966611 | ||||||||
| FaxNumber: | 5753964547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2011 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26460 | NE | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 8607 | SD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD443240 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD2017-0882 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.