Basic Information
| Provider Information | |||||||||
| NPI: | 1699757492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANKRATZ | ||||||||
| FirstName: | TOM | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 03/09/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 042315 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1009390 | 01 | WI | PHYS PLUS PROV # | OTHER | 551896 | 01 | WI | DEANCARE PROV # | OTHER | 388407992 | 01 | WI | TRICARE PROV # | OTHER | 430054481 | 01 | WI | RR MEDICARE PROV # | OTHER | 391023846 | 01 | WI | COMMERCIAL INS PROV # | OTHER | 43322800 | 05 | WI | MEDICAID |