Healthcare Provider Details

I. General information

NPI: 1760046932
Provider Name (Legal Business Name): ALEXANDRIA MARIE PONKRATZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W WILLIAMS ST STE 105
APEX NC
27502-3956
US

IV. Provider business mailing address

1021 W WILLIAMS ST STE 105
APEX NC
27502-3956
US

V. Phone/Fax

Practice location:
  • Phone: 919-290-1090
  • Fax:
Mailing address:
  • Phone: 919-290-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number250504
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2022-00431
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: