Provider Demographics
NPI:1699757492
Name:PANKRATZ, TOM R (CRNA)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:R
Last Name:PANKRATZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1539
Mailing Address - Country:US
Mailing Address - Phone:608-356-1400
Mailing Address - Fax:
Practice Address - Street 1:707 14TH ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1539
Practice Address - Country:US
Practice Address - Phone:608-356-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI042315367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1009390OtherPHYS PLUS PROV #
WI551896OtherDEANCARE PROV #
WI388407992OtherTRICARE PROV #
WI430054481OtherRR MEDICARE PROV #
WI391023846OtherCOMMERCIAL INS PROV #
WI43322800Medicaid
WIR39963Medicare UPIN
WI000221191Medicare ID - Type UnspecifiedPART B MEDICARE