Provider Demographics
NPI:1407692858
Name:ANNIS, JANESSA (PA-C)
Entity type:Individual
Prefix:
First Name:JANESSA
Middle Name:
Last Name:ANNIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JANESSA
Other - Middle Name:JEAN
Other - Last Name:ANNIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:987 R C HOAG DR
Mailing Address - Street 2:
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779-1365
Mailing Address - Country:US
Mailing Address - Phone:716-945-5894
Mailing Address - Fax:716-242-6345
Practice Address - Street 1:987 R C HOAG DR
Practice Address - Street 2:
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779-1365
Practice Address - Country:US
Practice Address - Phone:716-945-5894
Practice Address - Fax:716-242-6345
Is Sole Proprietor?:No
Enumeration Date:2024-07-05
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032870363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY08162512Medicaid