Provider Demographics
NPI:1538309885
Name:PANKEN, PETER (LAC)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:PANKEN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 RUGBY RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-6505
Mailing Address - Country:US
Mailing Address - Phone:917-697-0720
Mailing Address - Fax:
Practice Address - Street 1:495 RUGBY RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-6505
Practice Address - Country:US
Practice Address - Phone:917-697-0720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001095171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist