Provider Demographics
NPI:1346639176
Name:PENNER, MADELINE ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:ANNE
Last Name:PENNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE STE 1400
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2950 S ELM PL STE 256
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7871
Practice Address - Country:US
Practice Address - Phone:918-449-4061
Practice Address - Fax:918-449-4075
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant