Provider Demographics
NPI:1972534683
Name:PENNINGTON, MARVIN DEAN (PA)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:DEAN
Last Name:PENNINGTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3414 GOLDEN RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8336
Mailing Address - Country:US
Mailing Address - Phone:903-939-7500
Mailing Address - Fax:800-248-0426
Practice Address - Street 1:3414 GOLDEN RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8336
Practice Address - Country:US
Practice Address - Phone:903-939-7500
Practice Address - Fax:800-248-0426
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2024-05-19
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S82309Medicare UPIN