Provider Demographics
NPI:1619756814
Name:PENNONI, FRANK DENO (PA-C)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:DENO
Last Name:PENNONI
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 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-6592
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL STE 4460
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1168
Practice Address - Country:US
Practice Address - Phone:574-235-1010
Practice Address - Fax:574-647-2064
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004211A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300084606Medicaid