Healthcare Provider Details

I. General information

NPI: 1033154364
Provider Name (Legal Business Name): PAULA PONS PHYSICIAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4206 MEDICAL CENTER DR STE 203
FAYETTEVILLE NY
13066
US

IV. Provider business mailing address

5413 SPRINGVIEW DRIVE
FAYETTEVILLE NY
13066
US

V. Phone/Fax

Practice location:
  • Phone: 315-329-7770
  • Fax:
Mailing address:
  • Phone: 315-634-2003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number227287
License Number StateNY

VIII. Authorized Official

Name: PAULA PONS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 315-329-7003