Basic Information
| Provider Information | |||||||||
| NPI: | 1841841822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JALLAL | ||||||||
| FirstName: | ANISA | ||||||||
| MiddleName: | MEGHAN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5600 SPECTRA CIR APT 206 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339085442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172704865 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7335 GLADIOLUS DR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339085101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399851925 | ||||||||
| FaxNumber: | 2393216044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2019 | ||||||||
| LastUpdateDate: | 09/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1167615 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.