Provider Demographics
NPI:1801590765
Name:PONG, ROSABELLE (PA-C)
Entity type:Individual
Prefix:
First Name:ROSABELLE
Middle Name:
Last Name:PONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 I-35 N FRONTAGE RD.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-2113
Mailing Address - Country:US
Mailing Address - Phone:512-964-6992
Mailing Address - Fax:
Practice Address - Street 1:811 CARDIFF DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-2113
Practice Address - Country:US
Practice Address - Phone:917-325-5384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant