Provider Demographics
NPI:1790921344
Name:PONTIOUS, DAVID ERIC (MPAS, PAC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ERIC
Last Name:PONTIOUS
Suffix:
Gender:M
Credentials:MPAS, PAC
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Mailing Address - Street 1:3655 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4827
Mailing Address - Country:US
Mailing Address - Phone:801-293-3100
Mailing Address - Fax:801-293-1699
Practice Address - Street 1:3655 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-4827
Practice Address - Country:US
Practice Address - Phone:801-293-3100
Practice Address - Fax:801-293-1699
Is Sole Proprietor?:No
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT3604841206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant