Provider Demographics
NPI:1013216324
Name:PANKRATOVA, TATYANA (MD)
Entity Type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:
Last Name:PANKRATOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 G ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4112
Mailing Address - Country:US
Mailing Address - Phone:541-744-8613
Mailing Address - Fax:541-744-8608
Practice Address - Street 1:2128 BLAKESLEE BOULEVARD DR E
Practice Address - Street 2:
Practice Address - City:LEHIGHTON
Practice Address - State:PA
Practice Address - Zip Code:18235-9619
Practice Address - Country:US
Practice Address - Phone:610-402-5369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.017371207R00000X
ORMD176264207R00000X
WV25253207R00000X
PAMD448702207RH0003X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR189564Medicare PIN