1487300265 NPI number — MONTANA C PUCKETT PA-C

Table of content: MONTANA C PUCKETT PA-C (NPI 1487300265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487300265 NPI number — MONTANA C PUCKETT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUCKETT
Provider First Name:
MONTANA
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487300265
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19701 GULF BLVD UNIT 401
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIAN SHORES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33785-2386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-743-2276
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 ARLINGTON ST STE 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34239-3508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-921-2600
Provider Business Practice Location Address Fax Number:
941-925-8672
Provider Enumeration Date:
03/01/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA9115470 . This is a "FLORIDA LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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