Provider Demographics
NPI:1356845341
Name:PENNER, JOHN CORNELIUS
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CORNELIUS
Last Name:PENNER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JACK
Other - Middle Name:CORNELIUS
Other - Last Name:PENNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:609 CAYUGA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2413
Mailing Address - Country:US
Mailing Address - Phone:408-204-6990
Mailing Address - Fax:
Practice Address - Street 1:609 CAYUGA ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2413
Practice Address - Country:US
Practice Address - Phone:408-204-6990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA167392207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program