Healthcare Provider Details

I. General information

NPI: 1063395747
Provider Name (Legal Business Name): JAKOB PANKONIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 ROSEWOOD N
MT PLEASANT MI
48858-5003
US

IV. Provider business mailing address

2480 ROSEWOOD N
MT PLEASANT MI
48858-5003
US

V. Phone/Fax

Practice location:
  • Phone: 989-775-3823
  • Fax: 810-275-0307
Mailing address:
  • Phone: 989-775-3823
  • Fax: 810-275-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: