Provider Demographics
NPI:1508172016
Name:PONGRACZ, STEPHANIE E (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:E
Last Name:PONGRACZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:E
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1658 CAMDEN AVE
Mailing Address - Street 2:NO 105
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7548
Mailing Address - Country:US
Mailing Address - Phone:805-403-3755
Mailing Address - Fax:
Practice Address - Street 1:2020 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2023
Practice Address - Country:US
Practice Address - Phone:310-928-2663
Practice Address - Fax:310-315-2198
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20968363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEE223ZMedicare PIN