Provider Demographics
NPI:1194910984
Name:PENAS, BRANDON DARRELL
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:DARRELL
Last Name:PENAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9376 E BAHIA DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1532
Mailing Address - Country:US
Mailing Address - Phone:480-556-8406
Mailing Address - Fax:480-607-5840
Practice Address - Street 1:9376 E BAHIA DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1532
Practice Address - Country:US
Practice Address - Phone:480-556-8406
Practice Address - Fax:480-607-5840
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7735225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ117342Medicare PIN