Provider Demographics
NPI:1093148728
Name:TONGDEE, POETCHANAPORN BUNDIT (ARNP)
Entity Type:Individual
Prefix:
First Name:POETCHANAPORN
Middle Name:BUNDIT
Last Name:TONGDEE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 IRWIN ST W
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-2240
Mailing Address - Country:US
Mailing Address - Phone:727-798-2927
Mailing Address - Fax:727-798-2927
Practice Address - Street 1:1106 DRUID RD S
Practice Address - Street 2:SUITE 201
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3846
Practice Address - Country:US
Practice Address - Phone:727-584-6266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-16
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1478712363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL609593Medicaid