Provider Demographics
NPI:1821569245
Name:PONIKTERA, ALEXANDER JOHN (ATC, EMT-B)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JOHN
Last Name:PONIKTERA
Suffix:
Gender:M
Credentials:ATC, EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 NARROWS HILL RD
Mailing Address - Street 2:
Mailing Address - City:UPPER BLACK EDDY
Mailing Address - State:PA
Mailing Address - Zip Code:18972-9712
Mailing Address - Country:US
Mailing Address - Phone:610-603-6126
Mailing Address - Fax:
Practice Address - Street 1:1705 NARROWS HILL RD
Practice Address - Street 2:
Practice Address - City:UPPER BLACK EDDY
Practice Address - State:PA
Practice Address - Zip Code:18972-9712
Practice Address - Country:US
Practice Address - Phone:610-603-6126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
PA191326146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic