Healthcare Provider Details

I. General information

NPI: 1013216324
Provider Name (Legal Business Name): TATYANA PANKRATOVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2128 BLAKESLEE BOULEVARD DR E
LEHIGHTON PA
18235-9619
US

IV. Provider business mailing address

1460 G ST
SPRINGFIELD OR
97477-4112
US

V. Phone/Fax

Practice location:
  • Phone: 610-402-5369
  • Fax:
Mailing address:
  • Phone: 541-744-8613
  • Fax: 541-744-8608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD448702
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: