Provider Demographics
NPI:1457906083
Name:PONDEL, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PONDEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14139 E PLACITA ADAMAR
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-2190
Mailing Address - Country:US
Mailing Address - Phone:623-670-6242
Mailing Address - Fax:
Practice Address - Street 1:14139 E PLACITA ADAMAR
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-2190
Practice Address - Country:US
Practice Address - Phone:623-670-6242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider