Provider Demographics
NPI:1366547069
Name:PANKONIN, VINCENT WARD (D,C,)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:WARD
Last Name:PANKONIN
Suffix:
Gender:M
Credentials:D,C,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 3RD AVENUE SE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573
Mailing Address - Country:US
Mailing Address - Phone:218-340-7851
Mailing Address - Fax:218-347-1592
Practice Address - Street 1:720 3RD AVENUE SW
Practice Address - Street 2:SUITE 3
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573
Practice Address - Country:US
Practice Address - Phone:218-298-1886
Practice Address - Fax:218-347-1592
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC3066111N00000X
MN3066111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN455S6PAOtherBLUECROSS
MN507728100Medicaid
MN507728100Medicaid
MNP00019856Medicare ID - Type UnspecifiedRAILROAD
MN350002714Medicare ID - Type Unspecified