Provider Demographics
NPI:1346571692
Name:PONTICIAN, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PONTICIAN
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 1:553 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PORT CARBON
Mailing Address - State:PA
Mailing Address - Zip Code:17965-1721
Mailing Address - Country:US
Mailing Address - Phone:570-622-7785
Mailing Address - Fax:570-622-1774
Practice Address - Street 1:553 1ST ST
Practice Address - Street 2:
Practice Address - City:PORT CARBON
Practice Address - State:PA
Practice Address - Zip Code:17965-1721
Practice Address - Country:US
Practice Address - Phone:570-622-7785
Practice Address - Fax:570-622-1774
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA060799171WH0202X
171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
No171WV0202XOther Service ProvidersContractorVehicle Modifications