Basic Information
Provider Information | |||||||||
NPI: | 1649497082 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PONEMON | ||||||||
FirstName: | ROBERTA | ||||||||
MiddleName: | (M) | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 143 ORCHARD ST | ||||||||
Address2: |   | ||||||||
City: | DELMAR | ||||||||
State: | NY | ||||||||
PostalCode: | 12054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5184390517 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 47 NEW SCOTLAND AVE | ||||||||
Address2: |   | ||||||||
City: | ALBANY, | ||||||||
State: | NY | ||||||||
PostalCode: | 12208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5182624317 | ||||||||
FaxNumber: | 5182622671 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2007 | ||||||||
LastUpdateDate: | 05/27/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001586 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.