Healthcare Provider Details

I. General information

NPI: 1245417849
Provider Name (Legal Business Name): POORNIMA KUMAR PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1416 WEST FIRST STREET
SPRINGFIELD OH
45504-1923
US

IV. Provider business mailing address

1416 WEST FIRST STREET
SPRINGFIELD OH
45504-1923
US

V. Phone/Fax

Practice location:
  • Phone: 937-322-1700
  • Fax: 937-322-8070
Mailing address:
  • Phone: 937-322-1700
  • Fax: 937-322-8070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50002762
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1075639
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: