Provider Demographics
NPI:1790711992
Name:PANKOW, ANDREW D (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:D
Last Name:PANKOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 TONGASS AVE
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5746
Mailing Address - Country:US
Mailing Address - Phone:907-228-8300
Mailing Address - Fax:907-228-8518
Practice Address - Street 1:3100 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5746
Practice Address - Country:US
Practice Address - Phone:907-228-8140
Practice Address - Fax:907-228-8440
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3306207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA201209OtherWASHINGTON L&I
AKMD33061Medicaid
AKMD33061Medicaid
AKK160084Medicare PIN