Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 1179690 | TX |
NPI | 1992971899 |
---|---|
Provider Name | Michele E Pena |
First Address | San Antonio, TX 78229-4412 |
Second Address | San Antonio, TX 78229-4412 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2008 |
Last Update Date | 17/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1179690 | LICENSE (01) | TX |
1992971899 | (05) | TX |