Provider Demographics
NPI:1366448276
Name:PANKONIN, KYLE JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:JOHN
Last Name:PANKONIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 MAIN ST
Mailing Address - Street 2:PO BOX 517
Mailing Address - City:LAMBERTON
Mailing Address - State:MN
Mailing Address - Zip Code:56152-1377
Mailing Address - Country:US
Mailing Address - Phone:507-752-7650
Mailing Address - Fax:507-752-7635
Practice Address - Street 1:214 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAMBERTON
Practice Address - State:MN
Practice Address - Zip Code:56152-1377
Practice Address - Country:US
Practice Address - Phone:507-752-7650
Practice Address - Fax:507-752-7635
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC3858111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN15F52REOtherBLUE CROSS BLUE SHIELD
MN411508205OtherHEALTH SERVICES MANAGEMEN
MN411508205OtherHEALTH SERVICES MANAGEMEN
MNU78902Medicare UPIN
MN15F52REOtherBLUE CROSS BLUE SHIELD