Provider Demographics
NPI:1184209249
Name:PONTEJOS, MEINRADO
Entity Type:Individual
Prefix:
First Name:MEINRADO
Middle Name:
Last Name:PONTEJOS
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 1:7062 SNOWY CANYON DR UNIT 111
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8559
Mailing Address - Country:US
Mailing Address - Phone:904-866-5743
Mailing Address - Fax:
Practice Address - Street 1:7062 SNOWY CANYON DR UNIT 111
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-8559
Practice Address - Country:US
Practice Address - Phone:904-866-5743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11011020363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily