Healthcare Provider Details

I. General information

NPI: 1427325638
Provider Name (Legal Business Name): JEANETTE C. BANNISTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANETTE C. ALCORN

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13677 W MCDOWELL RD
GOODYEAR AZ
85395-2635
US

IV. Provider business mailing address

9250 N 3RD ST STE 3015
PHOENIX AZ
85020-2425
US

V. Phone/Fax

Practice location:
  • Phone: 623-536-4200
  • Fax: 623-935-0304
Mailing address:
  • Phone: 602-996-4747
  • Fax: 602-953-5466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001343A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5411
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: