Healthcare Provider Details

I. General information

NPI: 1649247362
Provider Name (Legal Business Name): PATRICK J PUCELIK ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 BLAIR ST
WHITING IA
51063-1007
US

IV. Provider business mailing address

153 BLAIR ST
WHITING IA
51063-1007
US

V. Phone/Fax

Practice location:
  • Phone: 712-455-2431
  • Fax: 712-455-2698
Mailing address:
  • Phone: 712-455-2431
  • Fax: 712-455-2698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA-106028
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA-106028
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: