Basic Information
| Provider Information | |||||||||
| NPI: | 1770755985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENN | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2520 CHERRY AVE | ||||||||
| Address2: | HARRISON MEDICAL CENTER | ||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983104229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603732547 | ||||||||
| FaxNumber: | 3604798268 | ||||||||
| Practice Location | |||||||||
| Address1: | 2709 HEMLOCK ST | ||||||||
| Address2: | HARRISON HEALTHPARTNERS CARDIOVASCULAR CONSULTANTS | ||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983102623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603732547 | ||||||||
| FaxNumber: | 3604798268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2008 | ||||||||
| LastUpdateDate: | 01/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208M00000X | 256268 | NY | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 256268 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | MD60544826 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | 054224 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 024975 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER | 2044356 | 05 | WA | MEDICAID | G8940389 | 01 | WA | MEDICARE | OTHER | 94509719 | 05 | CO | MEDICAID |