Provider Demographics
NPI:1821005463
Name:PANKOW, WILLIAM (APRN)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:PANKOW
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 OLD EUSTIS RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-9469
Mailing Address - Country:US
Mailing Address - Phone:540-455-2270
Mailing Address - Fax:
Practice Address - Street 1:1255 OLD EUSTIS RD STE 300
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-9469
Practice Address - Country:US
Practice Address - Phone:540-455-2270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9211637163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3516ZMedicare PIN