Provider Demographics
NPI:1780827816
Name:PATTANIYIL, JESSY TOM (NPC)
Entity type:Individual
Prefix:MRS
First Name:JESSY
Middle Name:TOM
Last Name:PATTANIYIL
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 HARBISON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-2912
Mailing Address - Country:US
Mailing Address - Phone:215-333-4300
Mailing Address - Fax:
Practice Address - Street 1:6501 HARBISON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2912
Practice Address - Country:US
Practice Address - Phone:215-333-4300
Practice Address - Fax:215-333-2044
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010182363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007278000OtherTPI MEDICAID GROUP ID
PA597586OtherTPI MEDICARE GROUP
PACD4829OtherTPI RAILROAD MEDICARE GROUP