Provider Demographics
NPI:1053637942
Name:PONGRACZ, BRIAN A (ACNP-BC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:PONGRACZ
Suffix:
Gender:M
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2624 EDITH AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-3043
Practice Address - Country:US
Practice Address - Phone:530-806-1190
Practice Address - Fax:530-229-7946
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-16
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012250363LA2100X, 363LG0600X
NYF430495-1363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology