Healthcare Provider Details

I. General information

NPI: 1255415014
Provider Name (Legal Business Name): DAVID A PONTON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 10/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 30TH AVE
LONG ISLAND CITY NY
11102-2448
US

IV. Provider business mailing address

2554 37TH ST
ASTORIA NY
11103-4247
US

V. Phone/Fax

Practice location:
  • Phone: 718-267-4245
  • Fax:
Mailing address:
  • Phone: 917-450-7986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number008960
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: