Provider Demographics
NPI:1790118636
Name:PENSE, NOEL C (DO)
Entity Type:Individual
Prefix:
First Name:NOEL
Middle Name:C
Last Name:PENSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89351 SUNNY LOOP LN
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-6346
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:702-453-5741
Practice Address - Street 1:94220 4TH ST
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-7756
Practice Address - Country:US
Practice Address - Phone:702-453-3799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004928207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500724810Medicaid