Provider Demographics
NPI:1871601575
Name:PENA, AMIE (NP)
Entity type:Individual
Prefix:
First Name:AMIE
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 N CENTRAL AVE
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2425
Mailing Address - Country:US
Mailing Address - Phone:602-406-3729
Mailing Address - Fax:602-798-9412
Practice Address - Street 1:500 W THOMAS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4224
Practice Address - Country:US
Practice Address - Phone:602-406-6262
Practice Address - Fax:602-406-6260
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ097145363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ754699Medicaid
AZP80089Medicare UPIN
AZ77869Medicare ID - Type UnspecifiedMEDICARE #
AZ754699Medicaid