Basic Information
| Provider Information | |||||||||
| NPI: | 1366641060 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANKO | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3427 E TUDOR RD | ||||||||
| Address2: | STE A | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995071282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074562784 | ||||||||
| FaxNumber: | 9074521073 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 COWLES ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074526464 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 10/21/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | S7195 | AK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD161185 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | MD9507 | 05 | AK | MEDICAID |