Provider Demographics
NPI:1881412112
Name:PONTOSKY, VAEDA
Entity type:Individual
Prefix:
First Name:VAEDA
Middle Name:
Last Name:PONTOSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 EASTON TPKE
Mailing Address - Street 2:
Mailing Address - City:LAKE ARIEL
Mailing Address - State:PA
Mailing Address - Zip Code:18436-4714
Mailing Address - Country:US
Mailing Address - Phone:570-466-7690
Mailing Address - Fax:
Practice Address - Street 1:12547 OCEAN GTWY
Practice Address - Street 2:
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842-9689
Practice Address - Country:US
Practice Address - Phone:410-213-0119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0009648363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty