Provider Demographics
NPI:1780837468
Name:PENREE, DONALD P JR (RPA-C)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:P
Last Name:PENREE
Suffix:JR
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3229 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-2016
Mailing Address - Country:US
Mailing Address - Phone:315-464-5726
Mailing Address - Fax:315-464-2500
Practice Address - Street 1:3229 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-2016
Practice Address - Country:US
Practice Address - Phone:315-464-5726
Practice Address - Fax:315-464-2500
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012929-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03081812Medicaid
NY03081812Medicaid