Healthcare Provider Details

I. General information

NPI: 1164084273
Provider Name (Legal Business Name): NATHAN WILLIAM PALUCH AA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 SIMMONS LOOP
RIVERVIEW FL
33578-9498
US

IV. Provider business mailing address

2995 DREW ST
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 813-302-8000
  • Fax:
Mailing address:
  • Phone: 727-315-7496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA543
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: