MEDICARE: DAVID PENNER MD PLLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407440001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID PENNER MD PLLC

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	:	DR
Name	:	DAVID EUGENE PENNER
Credential	:	MD
Telephone Number	:	360-539-1736

Provider Enumeration Date	:	02/24/2021
Last Update Date	:	10/25/2021

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