Provider Demographics
NPI:1215469598
Name:PENNER, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:PENNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LOTHROP ST STE E204
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-2536
Mailing Address - Country:US
Mailing Address - Phone:412-647-3550
Mailing Address - Fax:412-647-2601
Practice Address - Street 1:200 LOTHROP ST STE E204
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2536
Practice Address - Country:US
Practice Address - Phone:412-647-3550
Practice Address - Fax:412-647-2601
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4816282085R0204X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology