Provider Demographics
NPI:1770552747
Name:PANNELL, JOHN S (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:PANNELL
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 1:900 BUFFALO RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-2800
Mailing Address - Country:US
Mailing Address - Phone:570-524-4446
Mailing Address - Fax:570-522-1110
Practice Address - Street 1:900 BUFFALO RD
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-2800
Practice Address - Country:US
Practice Address - Phone:570-524-4446
Practice Address - Fax:570-522-1110
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP85251Medicare UPIN
PA068450Medicare ID - Type Unspecified