Provider Demographics
NPI:1962801381
Name:PENA, EDISON
Entity type:Individual
Prefix:
First Name:EDISON
Middle Name:
Last Name:PENA
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 1:45 FAIRVIEW AVE
Mailing Address - Street 2:APT T3A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-2718
Mailing Address - Country:US
Mailing Address - Phone:646-399-0463
Mailing Address - Fax:
Practice Address - Street 1:2226 LINDA AVENUE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532
Practice Address - Country:US
Practice Address - Phone:914-773-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program