Provider Demographics
NPI:1366879306
Name:PENG, MAYRA ALEXANDRA (PA-C)
Entity type:Individual
Prefix:MS
First Name:MAYRA
Middle Name:ALEXANDRA
Last Name:PENG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 E OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-7092
Mailing Address - Country:US
Mailing Address - Phone:805-737-3300
Mailing Address - Fax:
Practice Address - Street 1:1515 E OCEAN AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7092
Practice Address - Country:US
Practice Address - Phone:805-737-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017041798363A00000X
CA23217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant