Basic Information
| Provider Information | |||||||||
| NPI: | 1255773222 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANICI | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 GLENWOOD AVE | ||||||||
| Address2: | GLENWOOD AVENUE FOOT AND ANKLE, PLLC | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276082368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198290076 | ||||||||
| FaxNumber: | 9198369094 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 PARKWAY OFFICE CT STE 100 | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275187429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194813338 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2013 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 635 | NC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | 635 | NC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213EP1101X | 635 | NC | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4861725 | 01 | NC | AETNA | OTHER |