Provider Demographics
NPI:1013944974
Name:PENNER, KEITH EDWIN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:EDWIN
Last Name:PENNER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 OLD LEXINGTON RD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360-3428
Mailing Address - Country:US
Mailing Address - Phone:336-476-2586
Mailing Address - Fax:
Practice Address - Street 1:207 OLD LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-3428
Practice Address - Country:US
Practice Address - Phone:336-476-2586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC051810367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051375Medicaid
NC4630058715OtherRR MEDICARE
NC4630058715OtherRR MEDICARE