Provider Demographics
NPI:1417049032
Name:PENNEY, SHIRLEY A (PA)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:A
Last Name:PENNEY
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 1:621 S ILLINOIS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:641-494-3041
Mailing Address - Fax:641-494-3059
Practice Address - Street 1:140 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ST ANSGAR
Practice Address - State:IA
Practice Address - Zip Code:50472-0000
Practice Address - Country:US
Practice Address - Phone:641-736-4401
Practice Address - Fax:641-713-4977
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA866363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA10819OtherWELLMARK
IAR03115Medicare UPIN
IA48981Medicare ID - Type Unspecified