Provider Demographics
NPI:1205010477
Name:PANZERO, JAMIE D (RN, BSN)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:D
Last Name:PANZERO
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1055
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-1055
Mailing Address - Country:US
Mailing Address - Phone:907-398-2369
Mailing Address - Fax:907-262-6690
Practice Address - Street 1:36745 FUEDING LANE
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:AK
Practice Address - Zip Code:99672
Practice Address - Country:US
Practice Address - Phone:907-398-2369
Practice Address - Fax:907-262-6690
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM2874Medicaid