Healthcare Provider Details

I. General information

NPI: 1073539771
Provider Name (Legal Business Name): NICHOLAS ALEXANDER PUKISH JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 WALMART LN STE B
BILOXI MS
39531-4564
US

IV. Provider business mailing address

6255 W SUNSET BLVD FL 21
LOS ANGELES CA
90028-7422
US

V. Phone/Fax

Practice location:
  • Phone: 601-368-6254
  • Fax:
Mailing address:
  • Phone: 323-860-5200
  • Fax: 323-467-7119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 9100880
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00845
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: