Provider Demographics
NPI:1407589534
Name:PENN, CATESBY (PA)
Entity Type:Individual
Prefix:
First Name:CATESBY
Middle Name:
Last Name:PENN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E 62ND ST APT 2622
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4121
Mailing Address - Country:US
Mailing Address - Phone:678-925-8274
Mailing Address - Fax:
Practice Address - Street 1:109 E OGLETHORPE HWY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3657
Practice Address - Country:US
Practice Address - Phone:912-368-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant