Provider Demographics
NPI:1578663977
Name:PENNER, SANDY JAY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:SANDY
Middle Name:JAY
Last Name:PENNER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 WEST ELM STREET.
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:OK
Mailing Address - Zip Code:73651
Mailing Address - Country:US
Mailing Address - Phone:580-726-3324
Mailing Address - Fax:
Practice Address - Street 1:429 WEST ELM STREET.
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:OK
Practice Address - Zip Code:73651
Practice Address - Country:US
Practice Address - Phone:580-726-3324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0049080367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered