Provider Demographics
NPI:1285270785
Name:PONGVACHARARAK, AARON
Entity type:Individual
Prefix:
First Name:AARON
Middle Name:
Last Name:PONGVACHARARAK
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 1:411 N SAM HOUSTON PKWY E STE 280
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-3555
Mailing Address - Country:US
Mailing Address - Phone:346-888-5237
Mailing Address - Fax:
Practice Address - Street 1:411 N SAM HOUSTON PKWY E STE 280
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-3555
Practice Address - Country:US
Practice Address - Phone:346-888-5237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142310363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily