Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | 2020021408 | MO |
NPI | 1093093064 |
---|---|
Provider Name | Dr. Brenton Pennicooke |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Saint Louis, MO 63110-1032 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2011 |
Last Update Date | 25/01/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200085861 | (05) | MO |