Basic Information
| Provider Information | |||||||||
| NPI: | 1710955406 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANKAU | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2303 VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645064954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162326818 | ||||||||
| FaxNumber: | 8162322991 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 RHODE ISLAND | ||||||||
| Address2: | |||||||||
| City: | KING CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644630278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605354347 | ||||||||
| FaxNumber: | 6605356240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 103547 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 428705339 | 05 | MO | MEDICAID | 100288780D | 05 | KS | MEDICAID |