Provider Demographics
NPI:1689740136
Name:PENNER, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:PENNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11910 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2648
Mailing Address - Country:US
Mailing Address - Phone:202-816-2832
Mailing Address - Fax:
Practice Address - Street 1:11910 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2648
Practice Address - Country:US
Practice Address - Phone:202-816-2832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027481207Q00000X
NE12875207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine