Provider Demographics
NPI:1376663328
Name:PANNELL, JEREMY II
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:PANNELL
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6326 LEAFLET LN
Mailing Address - Street 2:
Mailing Address - City:HUGHSON
Mailing Address - State:CA
Mailing Address - Zip Code:95326-9124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 K ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1018
Practice Address - Country:US
Practice Address - Phone:209-523-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program