Healthcare Provider Details

I. General information

NPI: 1497109227
Provider Name (Legal Business Name): RALPH DAVID PUGH CSFA, ROT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 EL CAMINO REAL
LADY LAKE FL
32159-0041
US

IV. Provider business mailing address

1451 EL CAMINO REAL
LADY LAKE FL
32159-0041
US

V. Phone/Fax

Practice location:
  • Phone: 352-751-8000
  • Fax:
Mailing address:
  • Phone: 352-751-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number190611
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number040416060
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: