Provider Demographics
NPI:1417602145
Name:PONTIUS, MICHAEL EARL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EARL
Last Name:PONTIUS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CALUMET ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120-3651
Mailing Address - Country:US
Mailing Address - Phone:239-789-7402
Mailing Address - Fax:
Practice Address - Street 1:321 E ALBANY ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-2016
Practice Address - Country:US
Practice Address - Phone:315-867-2884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant