Provider Demographics
NPI:1912389123
Name:PENN, IAN
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:PENN
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 1:15 ROCHE BROS WAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-1000
Mailing Address - Country:US
Mailing Address - Phone:508-230-0155
Mailing Address - Fax:508-230-0145
Practice Address - Street 1:15 ROCHE BROS WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1000
Practice Address - Country:US
Practice Address - Phone:508-230-0155
Practice Address - Fax:508-230-0145
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2267783363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily