Basic Information
| Provider Information | |||||||||
| NPI: | 1194792531 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANKEWYCZ | ||||||||
| FirstName: | OLEH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 RANCHO LN. | ||||||||
| Address2: | STE 250 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023832224 | ||||||||
| FaxNumber: | 7023833035 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 RANCHO LN. | ||||||||
| Address2: | STE 250 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023832224 | ||||||||
| FaxNumber: | 7023833035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 221448 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 21454 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | MD061181L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 02192309 | 05 | NY | MEDICAID |