Provider Demographics
NPI:1922104991
Name:BURDICK, PENNY ILENE (MD)
Entity Type:Individual
Prefix:DR
First Name:PENNY
Middle Name:ILENE
Last Name:BURDICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:PENNY
Other - Middle Name:ILENE
Other - Last Name:WHITTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 664
Mailing Address - Street 2:
Mailing Address - City:CARLSBORG
Mailing Address - State:WA
Mailing Address - Zip Code:98324-0664
Mailing Address - Country:US
Mailing Address - Phone:360-461-4538
Mailing Address - Fax:360-477-4824
Practice Address - Street 1:91 BRITTANY LN
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-9360
Practice Address - Country:US
Practice Address - Phone:360-461-4538
Practice Address - Fax:360-477-4824
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3296BUOtherREGENCE PPN
WA0245680OtherWA STATE L&I PROVIDER ACCT. #
WA1127190Medicaid
A06863Medicare UPIN
WAG8879077Medicare PIN