Provider Demographics
NPI:1538311691
Name:PANISI, UAISELE FORREST (PA-C)
Entity Type:Individual
Prefix:MR
First Name:UAISELE
Middle Name:FORREST
Last Name:PANISI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 S 500 E
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1959
Mailing Address - Country:US
Mailing Address - Phone:801-587-6308
Mailing Address - Fax:
Practice Address - Street 1:1525 W 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-1401
Practice Address - Country:US
Practice Address - Phone:801-213-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT379299-1206363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant