Provider Demographics
NPI:1225218555
Name:PONKRATOV, EVGENY
Entity Type:Individual
Prefix:
First Name:EVGENY
Middle Name:
Last Name:PONKRATOV
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 1:900 E KAREN AVE STE C114
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-1275
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 E KAREN AVE STE C114
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-1275
Practice Address - Country:US
Practice Address - Phone:702-481-5368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-03
Last Update Date:2007-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVH13-00316332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies