Provider Demographics
NPI:1023065125
Name:PONITZ, MARTHA JEAN (CRNA)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:JEAN
Last Name:PONITZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:JEAN
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:44 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6673
Mailing Address - Country:US
Mailing Address - Phone:207-872-1136
Mailing Address - Fax:
Practice Address - Street 1:149 NORTH ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4974
Practice Address - Country:US
Practice Address - Phone:207-872-1270
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME019370367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM2622Medicare ID - Type Unspecified