Provider Demographics
NPI:1679550040
Name:PENNER, PAMELA A (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:PENNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W SALISBURY ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-5497
Mailing Address - Country:US
Mailing Address - Phone:336-636-5100
Mailing Address - Fax:336-636-5144
Practice Address - Street 1:515 W SALISBURY ST
Practice Address - Street 2:SUITE D
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5497
Practice Address - Country:US
Practice Address - Phone:336-636-5100
Practice Address - Fax:336-636-5144
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200101484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2295893AMedicare PIN
NCG47907Medicare UPIN