Provider Demographics
NPI:1649212135
Name:PONGRATZ, ANISSA L (MPT)
Entity Type:Individual
Prefix:MRS
First Name:ANISSA
Middle Name:L
Last Name:PONGRATZ
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 W SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-5004
Mailing Address - Country:US
Mailing Address - Phone:602-222-3032
Mailing Address - Fax:480-615-1117
Practice Address - Street 1:641 W SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-5004
Practice Address - Country:US
Practice Address - Phone:602-222-3032
Practice Address - Fax:480-615-1117
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5241225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5241OtherPT LICENSE #
AZ864399Medicaid
AZ864399Medicaid
AZ81712Medicare PIN