Provider Demographics
NPI:1427325638
Name:BANNISTER, JEANETTE C (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:C
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:C
Other - Last Name:ALCORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9250 N 3RD ST STE 3015
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2425
Mailing Address - Country:US
Mailing Address - Phone:602-996-4747
Mailing Address - Fax:602-953-5466
Practice Address - Street 1:13677 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2635
Practice Address - Country:US
Practice Address - Phone:623-536-4200
Practice Address - Fax:623-935-0304
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001343A363A00000X
AZ5411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ827411Medicaid
AZ827411Medicaid
INM400060855Medicare PIN