Provider Demographics
NPI:1396779716
Name:PANNKE, THOMAS SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:SCOTT
Last Name:PANNKE
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:601 MARTIN LUTHER KING AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3619
Practice Address - Country:US
Practice Address - Phone:505-727-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60793240207P00000X
WI41606-020207P00000X
WY9372-A207PE0004X
NMMD2014-0522207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI930079986OtherMEDICARE RAILROAD
WI31814700Medicaid
WI930078269OtherMEDICARE RAILROAD
MI104160666Medicaid
WI930106591OtherMEDICARE RAILROAD
WI930079986OtherMEDICARE RAILROAD
WI0035-07660Medicare ID - Type Unspecified
MI104160666Medicaid
WI0026-71116Medicare ID - Type Unspecified
WI0010-40115Medicare ID - Type Unspecified
WI0009-17130Medicare ID - Type Unspecified
WI930078269OtherMEDICARE RAILROAD