Provider Demographics
NPI:1457680613
Name:PENNER, IAN RICHARD (PA-C)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:RICHARD
Last Name:PENNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3209
Mailing Address - Country:US
Mailing Address - Phone:503-335-8141
Mailing Address - Fax:
Practice Address - Street 1:51377 SW OLD PORTLAND RD
Practice Address - Street 2:
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-4018
Practice Address - Country:US
Practice Address - Phone:503-543-3181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-17
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant