Provider Demographics
NPI:1891014999
Name:PONZI, CORINNE R (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CORINNE
Middle Name:R
Last Name:PONZI
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 1:1130 ANNAPOLIS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1622
Mailing Address - Country:US
Mailing Address - Phone:410-672-2255
Mailing Address - Fax:
Practice Address - Street 1:1130 ANNAPOLIS RD STE 101
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1622
Practice Address - Country:US
Practice Address - Phone:410-672-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9104925363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant