Provider Demographics
NPI:1831068683
Name:PONNA, AMULYA
Entity type:Individual
Prefix:
First Name:AMULYA
Middle Name:
Last Name:PONNA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 DONOVAN WAY
Mailing Address - Street 2:
Mailing Address - City:CHESTER SPRINGS
Mailing Address - State:PA
Mailing Address - Zip Code:19425-3678
Mailing Address - Country:US
Mailing Address - Phone:610-458-7365
Mailing Address - Fax:
Practice Address - Street 1:590 RADIO HILL RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4465
Practice Address - Country:US
Practice Address - Phone:610-458-7365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-31
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant