Basic Information
| Provider Information | |||||||||
| NPI: | 1093205098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENA | ||||||||
| FirstName: | LESTER JOHN | ||||||||
| MiddleName: | TIGLAO | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 GIBSON AVE APT 2F | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106071645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085935375 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3030 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | PURCHASE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105772574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146826435 | ||||||||
| FaxNumber: | 9146813115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2018 | ||||||||
| LastUpdateDate: | 12/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NY | MEDICAID |