Healthcare Provider Details

I. General information

NPI: 1174811343
Provider Name (Legal Business Name): JONATHAN W. PONTE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SUMMER ST SUITE 320
WORCESTER MA
01608-1216
US

IV. Provider business mailing address

630 PLANTATION ST WOT 12TH FL
WORCESTER MA
01605-2038
US

V. Phone/Fax

Practice location:
  • Phone: 508-368-3140
  • Fax: 508-368-3143
Mailing address:
  • Phone: 508-368-5424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN2264431
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: