Provider Demographics
NPI:1952153314
Name:PANICKER, JISHA TONY
Entity Type:Individual
Prefix:
First Name:JISHA
Middle Name:TONY
Last Name:PANICKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JISHA
Other - Middle Name:MULLASSERIL
Other - Last Name:TITUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1854 S PENNFIELD LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2559
Mailing Address - Country:US
Mailing Address - Phone:408-230-4878
Mailing Address - Fax:
Practice Address - Street 1:6111 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-5714
Practice Address - Country:US
Practice Address - Phone:517-393-3447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program