Basic Information
| Provider Information | |||||||||
| NPI: | 1427069392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENNY | ||||||||
| FirstName: | HEATHER | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 W BALTIMORE PIKE | ||||||||
| Address2: | SUITE4 200 | ||||||||
| City: | WEST GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193909313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108694627 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 W BALTIMORE PIKE | ||||||||
| Address2: | SUITE4 200 | ||||||||
| City: | WEST GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193909313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108694627 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 12/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C5-0000360 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | C0002644 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | MA003295L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1031928280001 | 05 | PA | MEDICAID |