Healthcare Provider Details

I. General information

NPI: 1720753544
Provider Name (Legal Business Name): CAMERON PUGACH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W MARKET ST FL 2
GREENSBORO NC
27403-1830
US

IV. Provider business mailing address

1100 W MARKET ST FL 2
GREENSBORO NC
27403-1830
US

V. Phone/Fax

Practice location:
  • Phone: 336-334-5662
  • Fax: 336-334-5754
Mailing address:
  • Phone: 336-334-3453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5906
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: