Provider Demographics
NPI:1770767949
Name:JAMIE PANZERO
Entity type:Organization
Organization Name:JAMIE PANZERO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PANZERO
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN
Authorized Official - Phone:907-398-2369
Mailing Address - Street 1:PO BOX 1055
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-1055
Mailing Address - Country:US
Mailing Address - Phone:907-398-2369
Mailing Address - Fax:907-262-6690
Practice Address - Street 1:36745 FUEDING LANE
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:AK
Practice Address - Zip Code:99672
Practice Address - Country:US
Practice Address - Phone:907-398-2369
Practice Address - Fax:907-262-6690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG874Medicaid