Provider Demographics
NPI:1841777190
Name:PONSOLL, KATELYN S (PA-C)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:S
Last Name:PONSOLL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:S
Other - Last Name:REISENAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:814-868-2529
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:5535 PEACH ST FL 1
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2603
Practice Address - Country:US
Practice Address - Phone:814-868-3488
Practice Address - Fax:814-868-3499
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059802363AM0700X
PAOA007090363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical