NPIMap

Individual provider Active NPI

Ian Richard Penner, PA-C

  • Medical Physician Assistant
  • Scappoose, OR
National Provider Identifier
1457680613
Registry record updated Dec 29, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
Practice address
51377 SW Old Portland Rd
Scappoose, OR 97056-4018
Phone
(503) 543-3181
NPI assigned
Dec 17, 2009
Last updated
Dec 29, 2020By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 29, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X Primary
Physician Assistant 363A00000X

Addresses

Primary practice location

51377 SW Old Portland Rd
Scappoose, OR 97056-4018

Mailing address

2717 NE 10TH Ave
Portland, OR 97212-3209
Phone (503) 335-8141

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20100608000107 OR Practitioner - Physician Assistant 4183768559 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2009
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

3930 SE Division St
Portland, OR 97202-1643
Phone (503) 418-3900

51377 SW Old Portland Rd
Scappoose, OR 97056-4023
Phone (503) 418-4222

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
University Professional Services CurrentSince Mar 1, 2010 Accepting new patients
Oregon Health & Science University CurrentSince Sep 26, 2010 Accepting new patients
Oregon Health & Science University CurrentSince Sep 26, 2010 Accepting new patients
University Professional Services CurrentSince Mar 1, 2010 Accepting new patients

Locations

15700 SW Greystone Ct
Beaverton, OR 97006
Phone (503) 203-1000

3181 SW Sam Jackson Park Rd
Portland, OR 97239
Phone (503) 494-5674

3930 SE Division St
Portland, OR 97202
Phone (503) 418-3900

51377 SW Old Portland Rd
Scappoose, OR 97056
Phone (503) 418-4222

Interoperability endpoints

  • Direct secure messaging: ipennerpa17140@direct.ohsu.edu

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 15

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1261008000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1609200000000",
    "number": "1457680613",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2717 NE 10TH AVE",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972123209",
            "telephone_number": "503-335-8141"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "51377 SW OLD PORTLAND RD",
            "city": "SCAPPOOSE",
            "state": "OR",
            "postal_code": "970564018",
            "telephone_number": "503-543-3181"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PENNER",
        "first_name": "IAN",
        "middle_name": "RICHARD",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2009-12-17",
        "last_updated": "2020-12-29",
        "certification_date": "2020-12-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Scappoose, OR

Sources for this page

Verify at the official NPI Registry.