Provider Demographics
NPI:1487632535
Name:PENHOLLOW, TAMMY JOLENE (DO)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:JOLENE
Last Name:PENHOLLOW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18444 N 25TH AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:13400 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-5452
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-07
Last Update Date:2020-09-08
Deactivation Date:2010-02-18
Deactivation Code:
Reactivation Date:2011-06-13
Provider Licenses
StateLicense IDTaxonomies
AZ005934207LP2900X, 207L00000X, 207LP2900X, 208600000X, 207L00000X
CA20A7735208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDIINGMedicaid
AZZ169738Medicare PIN