Provider Demographics
NPI:1023451101
Name:PENNISTON, IAN JOSEPH (DO)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:JOSEPH
Last Name:PENNISTON
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 1:6900 N PECOS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89086-4400
Mailing Address - Country:US
Mailing Address - Phone:702-791-9000
Mailing Address - Fax:
Practice Address - Street 1:6900 N PECOS RD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086-4400
Practice Address - Country:US
Practice Address - Phone:702-791-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN597782083A0300X, 2084P0800X, 208VP0000X, 2084B0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine