Provider Demographics
NPI:1902338072
Name:PANKIW, BRYAN (PTA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:PANKIW
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 PARRISH ST STE A
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1785
Mailing Address - Country:US
Mailing Address - Phone:585-393-0554
Mailing Address - Fax:585-393-0676
Practice Address - Street 1:275 PARRISH ST STE A
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1785
Practice Address - Country:US
Practice Address - Phone:585-393-0554
Practice Address - Fax:585-393-0676
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8754266225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant