1104602390 NPI number — MRS. CARLA FERNANDA PENA DE LA PAZ OTR

Table of content: MRS. CARLA FERNANDA PENA DE LA PAZ OTR (NPI 1104602390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104602390 NPI number — MRS. CARLA FERNANDA PENA DE LA PAZ OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENA DE LA PAZ
Provider First Name:
CARLA
Provider Middle Name:
FERNANDA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PENA
Provider Other First Name:
CARLA
Provider Other Middle Name:
FERNANDA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1104602390
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5215 N MCCOLL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78504-2202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3003 SAN ESTEBAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISSION
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78572-8621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-776-5991
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  119372 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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