Active NPI
Gary Penner
- Family Medicine Physician
- Fairfax, VA
National Provider Identifier
1689740136
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 0101027481
- Practice address
- 11910 Parkside Dr
Fairfax, VA 22033-2648 - Phone
- (202) 816-2832
- NPI assigned
- Nov 27, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 0101027481 | VA | Primary |
| Family Medicine Physician | 207Q00000X | 12875 | NE |
Addresses
Primary practice location
11910 Parkside Dr
Fairfax, VA 22033-2648
Mailing address
11910 Parkside Dr
Fairfax, VA 22033-2648
Phone (202) 816-2832
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12875 | NE | MD | Mental Health Counselor |
| 0101027481 | VA | MD | Family Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1164585600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1646697600000",
"number": "1689740136",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11910 PARKSIDE DR",
"city": "FAIRFAX",
"state": "VA",
"postal_code": "220332648",
"telephone_number": "202-816-2832"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11910 PARKSIDE DR",
"city": "FAIRFAX",
"state": "VA",
"postal_code": "220332648",
"telephone_number": "202-816-2832"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PENNER",
"first_name": "GARY",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-11-27",
"last_updated": "2022-03-08",
"certification_date": "2022-03-08",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "VA",
"license": "0101027481",
"primary": true
},
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "NE",
"license": "12875",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fairfax, VA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 8, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.