Provider Demographics
NPI:1710520390
Name:PONTON, KARLA VALLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KARLA
Middle Name:VALLE
Last Name:PONTON
Suffix:
Gender:F
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 1:10406 LESLIE DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-1272
Mailing Address - Country:US
Mailing Address - Phone:443-367-1484
Mailing Address - Fax:
Practice Address - Street 1:10406 LESLIE DR
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-1272
Practice Address - Country:US
Practice Address - Phone:443-367-1484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007347363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant