MEDICARE: DR. DAVID EUGENE PENNER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	228522	MA
2	2084P0800X	Psychiatry Physician	MD60191191	WA
3	2084P0804X	Child & Adolescent Psychiatry Physician	MD60191191	WA

General Provider Information

NPI Number	:	1114005584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID EUGENE PENNER MD

Provider Business Mailing Address
First Line	:	PO BOX 23
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98507-0023
Country	:	US
Telephone Number	:	360-539-1736
Fax Number	:	360-350-5610

Provider Business Practice Location Address
First Line	:	1801 W BAY DR NW STE 104
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-4310
Country	:	US
Telephone Number	:	360-539-1736
Fax Number	:	360-350-5610

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	05/17/2020

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