Provider Demographics
NPI:1285699488
Name:PANKE, RANDY L (NCCPA)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:L
Last Name:PANKE
Suffix:
Gender:M
Credentials:NCCPA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PSC 1005 BOX 11185
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:34009-0112
Mailing Address - Country:US
Mailing Address - Phone:757-458-2998
Mailing Address - Fax:
Practice Address - Street 1:159 TROUT AVE
Practice Address - Street 2:NAVSUBASE NLON
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-5159
Practice Address - Country:US
Practice Address - Phone:860-694-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2024-07-24
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant