Provider Demographics
NPI:1861906695
Name:PONSAA, RENE AUGUST III (ATC, LAT)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:AUGUST
Last Name:PONSAA
Suffix:III
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36326 CRESTWAY AVE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36326 CRESTWAY AVE
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3272
Practice Address - Country:US
Practice Address - Phone:985-687-5348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATH2000192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer