Provider Demographics
NPI:1366225013
Name:PENA, MARCOS JOSUE
Entity type:Individual
Prefix:
First Name:MARCOS
Middle Name:JOSUE
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 1:1075 E BETTERAVIA RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-7023
Mailing Address - Country:US
Mailing Address - Phone:805-621-7651
Mailing Address - Fax:
Practice Address - Street 1:2940 W MOVI TRL
Practice Address - Street 2:
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-5083
Practice Address - Country:US
Practice Address - Phone:805-793-9548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant