Provider Demographics
NPI:1558851535
Name:PON, CARLY (PTA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:PON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 MEDAU PLACE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-2809
Mailing Address - Country:US
Mailing Address - Phone:510-339-2116
Mailing Address - Fax:510-339-0647
Practice Address - Street 1:6116 MEDAU PL
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-2809
Practice Address - Country:US
Practice Address - Phone:510-339-2116
Practice Address - Fax:510-339-0647
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT49084225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant