Healthcare Provider Details

I. General information

NPI: 1699480673
Provider Name (Legal Business Name): NICHOLAS PENNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2023
Last Update Date: 02/02/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 LUJAN HILL RD
LAS CRUCES NM
88007-6304
US

IV. Provider business mailing address

5031 WESTFIELD DR NE
RIO RANCHO NM
87144-6564
US

V. Phone/Fax

Practice location:
  • Phone: 575-523-4573
  • Fax:
Mailing address:
  • Phone: 661-547-6380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1599
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: