Provider Demographics
NPI:1609909142
Name:PENWRIGHT, LARRY PAUL JR (HIS)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:PAUL
Last Name:PENWRIGHT
Suffix:JR
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 N BROADWAY AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3457
Mailing Address - Country:US
Mailing Address - Phone:580-436-3277
Mailing Address - Fax:580-436-5046
Practice Address - Street 1:703 N BROADWAY AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3457
Practice Address - Country:US
Practice Address - Phone:580-436-3277
Practice Address - Fax:580-436-5046
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK595174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist