Basic Information
| Provider Information | |||||||||
| NPI: | 1528059672 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PONNAIYA | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3022 S DURANGO DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891174440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022563637 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1795 DR FRANK GASTON BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297321190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022563637 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 10806 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1528059672 | 05 | NV | MEDICAID |