Provider Demographics
NPI:1083866776
Name:PANETTA, ANJA SUMMERS (PA)
Entity Type:Individual
Prefix:
First Name:ANJA
Middle Name:SUMMERS
Last Name:PANETTA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANJA
Other - Middle Name:MARIE
Other - Last Name:SUMMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:30 WEST AVON ROAD
Mailing Address - Street 2:SUITE E
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-4275
Mailing Address - Country:US
Mailing Address - Phone:860-674-9900
Mailing Address - Fax:860-678-0036
Practice Address - Street 1:30 WEST AVON ROAD
Practice Address - Street 2:SUITE E
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-4275
Practice Address - Country:US
Practice Address - Phone:860-674-9900
Practice Address - Fax:860-678-0036
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003080363A00000X, 363AS0400X, 363AM0700X
NY012881363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003030806Medicaid