Provider Demographics
NPI:1245935204
Name:PONG, MARTIN NGU KWALE (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:NGU KWALE
Last Name:PONG
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4338 W THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031-3878
Mailing Address - Country:US
Mailing Address - Phone:682-307-0864
Mailing Address - Fax:
Practice Address - Street 1:4338 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-3878
Practice Address - Country:US
Practice Address - Phone:682-307-0864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-31
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ280285363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health