Basic Information
| Provider Information | |||||||||
| NPI: | 1417257502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANNELL | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SISCO | ||||||||
| OtherFirstName: | JESSE | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3131 PRINCETON PIKE | ||||||||
| Address2: | STE 208 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086482201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098157829 | ||||||||
| FaxNumber: | 6098157894 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 BRUNSWICK AVE | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086384143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093946000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2010 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA054714 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 25MP00251400 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.