Basic Information
Provider Information | |||||||||
NPI: | 1023050200 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAKPREO | ||||||||
FirstName: | PONRAT | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 421 | ||||||||
Address2: |   | ||||||||
City: | LIBERTY LAKE | ||||||||
State: | WA | ||||||||
PostalCode: | 990190421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098938140 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1212 N PINES RD | ||||||||
Address2: |   | ||||||||
City: | SPOKANE VALLEY | ||||||||
State: | WA | ||||||||
PostalCode: | 992064939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098938140 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2006 | ||||||||
LastUpdateDate: | 03/06/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 224294 | NY | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080A0000X | 224294 | NY | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208000000X | MD00047151 | WA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080A0000X | MD00047151 | WA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
ID | Type | State | Issuer | Description | 02689641 | 05 | NY |   | MEDICAID | 8468340 | 05 | WA |   | MEDICAID | AB32999 | 01 | WA | MEDICARE GROUP | OTHER |