Provider Demographics
NPI:1023572294
Name:PONDER, COLBY
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:
Last Name:PONDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2434 S EASON BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-6942
Mailing Address - Country:US
Mailing Address - Phone:662-640-4595
Mailing Address - Fax:662-680-6416
Practice Address - Street 1:105 W HAMILTON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2209
Practice Address - Country:US
Practice Address - Phone:662-598-8141
Practice Address - Fax:662-796-3126
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903137363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018203Medicaid