Healthcare Provider Details

I. General information

NPI: 1962634659
Provider Name (Legal Business Name): JEAN J PANTAL CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SHALLCROSS AVE STE 1A
WILMINGTON DE
19806-3037
US

IV. Provider business mailing address

1500 SHALLCROSS AVE
WILMINGTON DE
19806-3037
US

V. Phone/Fax

Practice location:
  • Phone: 302-200-5080
  • Fax:
Mailing address:
  • Phone: 302-200-5080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP010360
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License NumberSP010360
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberSP010360
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP010360
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: