Provider Demographics
NPI:1750498986
Name:PENNER, TOBY ALLEN (CRNA, MSN)
Entity Type:Individual
Prefix:
First Name:TOBY
Middle Name:ALLEN
Last Name:PENNER
Suffix:
Gender:M
Credentials:CRNA, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 274
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-0274
Mailing Address - Country:US
Mailing Address - Phone:541-564-4466
Mailing Address - Fax:541-564-4466
Practice Address - Street 1:610 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-6601
Practice Address - Country:US
Practice Address - Phone:541-667-3406
Practice Address - Fax:541-667-3420
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered