Provider Demographics
NPI:1629414123
Name:TANKOVICH, MICHAEL JAMES (PT, DPT, ATC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:TANKOVICH
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SEAHAWKS WAY
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-1572
Mailing Address - Country:US
Mailing Address - Phone:425-203-8278
Mailing Address - Fax:425-203-8275
Practice Address - Street 1:12 SEAHAWKS WAY
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-1572
Practice Address - Country:US
Practice Address - Phone:425-203-8278
Practice Address - Fax:425-203-8275
Is Sole Proprietor?:No
Enumeration Date:2013-05-11
Last Update Date:2013-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT 602936332251S0007X
WAA1 602948522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer