Provider Demographics
NPI:1194396804
Name:PANKEY, TYSON LUCIAN SYDNEY (PHD, MPH)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:LUCIAN SYDNEY
Last Name:PANKEY
Suffix:
Gender:M
Credentials:PHD, MPH
Other - Prefix:
Other - First Name:TYSON
Other - Middle Name:
Other - Last Name:PANKEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, MPH
Mailing Address - Street 1:544 PROVIDENCE ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0002
Practice Address - Country:US
Practice Address - Phone:913-558-4193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-03
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist