MEDICARE: PAUL R PONNAIYA MD A PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208M00000X	Hospitalist Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1386079184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAUL R PONNAIYA MD A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	3022 S DURANGO DR STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-4440
Country	:	US
Telephone Number	:	702-256-3637
Fax Number	:	702-405-8895

Provider Business Practice Location Address
First Line	:	1795 DR FRANK GASTON BLVD
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-1190
Country	:	US
Telephone Number	:	702-256-3637
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PAUL R PONNAIYA
Credential	:	MD
Telephone Number	:	702-388-9777

Provider Enumeration Date	:	09/11/2013
Last Update Date	:	08/12/2022

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