Healthcare Provider Details

I. General information

NPI: 1528685054
Provider Name (Legal Business Name): TORRENCE PUCK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N STATE COLLEGE BLVD STE H
FULLERTON CA
92831-4236
US

IV. Provider business mailing address

100 N STATE COLLEGE BLVD STE H
FULLERTON CA
92831-4236
US

V. Phone/Fax

Practice location:
  • Phone: 714-824-6565
  • Fax: 714-930-7926
Mailing address:
  • Phone: 714-824-6565
  • Fax: 714-930-7926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA58520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: