Provider Demographics
NPI:1699190157
Name:PANCOAST, PAUL EDWARD (ME)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWARD
Last Name:PANCOAST
Suffix:
Gender:M
Credentials:ME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 S VINEYARD WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-9505
Mailing Address - Country:US
Mailing Address - Phone:214-799-6073
Mailing Address - Fax:
Practice Address - Street 1:4401 S VINEYARD WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-9505
Practice Address - Country:US
Practice Address - Phone:214-799-6073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048028207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine