Provider Demographics
NPI:1427136423
Name:PONGKLANG, NARISA
Entity type:Individual
Prefix:MRS
First Name:NARISA
Middle Name:
Last Name:PONGKLANG
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 1:1220 RT 46 W
Mailing Address - Street 2:
Mailing Address - City:PARSIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07054
Mailing Address - Country:US
Mailing Address - Phone:973-299-1110
Mailing Address - Fax:973-299-0667
Practice Address - Street 1:1220 RT 46 W
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054
Practice Address - Country:US
Practice Address - Phone:973-299-1110
Practice Address - Fax:973-299-0667
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3935830001225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
3935830001Medicare UPIN
NJ3935830001Medicare NSC