Basic Information
| Provider Information | |||||||||
| NPI: | 1093148728 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TONGDEE | ||||||||
| FirstName: | POETCHANAPORN | ||||||||
| MiddleName: | BUNDIT | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65 IRWIN ST W | ||||||||
| Address2: | |||||||||
| City: | SAFETY HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346952240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277982927 | ||||||||
| FaxNumber: | 7277982927 | ||||||||
| Practice Location | |||||||||
| Address1: | 1106 DRUID RD S | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275846266 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2013 | ||||||||
| LastUpdateDate: | 03/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP1478712 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | ARNP1478712 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 609593 | 05 | FL | MEDICAID |