Provider Demographics
NPI:1023050200
Name:PAKPREO, PONRAT (MD)
Entity type:Individual
Prefix:DR
First Name:PONRAT
Middle Name:
Last Name:PAKPREO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-893-8140
Mailing Address - Fax:
Practice Address - Street 1:16528 E DESMET CT STE B-1000
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-3522
Practice Address - Country:US
Practice Address - Phone:509-944-8860
Practice Address - Fax:509-944-8856
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224294208000000X, 2080A0000X
WAMD00047151208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8468340Medicaid
NY02689641Medicaid
WAAB32999OtherMEDICARE GROUP
WAG8862434Medicare PIN
NY02689641Medicaid
WAI46512Medicare UPIN