Provider Demographics
NPI:1710387121
Name:POND, AMY M (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:POND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 305
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-266-8900
Practice Address - Fax:260-266-8935
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11421363A00000X
OH004085363A00000X
IN10001828A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153449704OtherMEDICAID GRP PRACTICE TPI #
TX00106WOtherMEDICARE GRP PTAN #
TX0035TDOtherBCBSTX GRP PRACTICE RECORD #