Healthcare Provider Details

I. General information

NPI: 1487300265
Provider Name (Legal Business Name): MONTANA C PUCKETT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 ARLINGTON ST STE 111
SARASOTA FL
34239-3508
US

IV. Provider business mailing address

19701 GULF BLVD UNIT 401
INDIAN SHORES FL
33785-2386
US

V. Phone/Fax

Practice location:
  • Phone: 941-921-2600
  • Fax: 941-925-8672
Mailing address:
  • Phone: 727-743-2276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: