Healthcare Provider Details

I. General information

NPI: 1598167074
Provider Name (Legal Business Name): JON PENNINGTON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14520 W GRANITE VALLEY DR STE 210
SUN CITY WEST AZ
85375-5855
US

IV. Provider business mailing address

14520 W GRANITE VALLEY DR STE 210
SUN CITY WEST AZ
85375-5855
US

V. Phone/Fax

Practice location:
  • Phone: 866-974-2673
  • Fax: 866-939-2673
Mailing address:
  • Phone: 866-974-2673
  • Fax: 866-939-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9035
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60600014
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: