Provider Demographics
NPI:1184130908
Name:PANNACHAN, BINU (NP)
Entity type:Individual
Prefix:
First Name:BINU
Middle Name:
Last Name:PANNACHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 JEFFERSON DAVIS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-5120
Mailing Address - Country:US
Mailing Address - Phone:601-273-3554
Mailing Address - Fax:601-653-9589
Practice Address - Street 1:150 JEFFERSON DAVIS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-5120
Practice Address - Country:US
Practice Address - Phone:601-273-3554
Practice Address - Fax:601-653-9589
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902441363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08452308Medicaid
LA2478893Medicaid