Provider Demographics
NPI:1508879370
Name:PANNILL, MALCOLM HART II (PAC)
Entity Type:Individual
Prefix:MR
First Name:MALCOLM
Middle Name:HART
Last Name:PANNILL
Suffix:II
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2920 HIGHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-0010
Mailing Address - Country:US
Mailing Address - Phone:877-498-4490
Mailing Address - Fax:
Practice Address - Street 1:3024 NEW BERN AVE
Practice Address - Street 2:SUITE 306 - OB/GYN
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1247
Practice Address - Country:US
Practice Address - Phone:919-350-8535
Practice Address - Fax:919-350-8310
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2753136Medicare ID - Type Unspecified
P27446Medicare UPIN