Healthcare Provider Details

I. General information

NPI: 1730775875
Provider Name (Legal Business Name): NATHANIEL JOSEPH PUCHALA IDHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ERIE INDUSTRIAL PARK BLDG 360
PORT CLINTON OH
43452-9412
US

IV. Provider business mailing address

ERIE INDUSTRIAL PARK BLDG 360
PORT CLINTON OH
43452-9412
US

V. Phone/Fax

Practice location:
  • Phone: 419-635-4462
  • Fax:
Mailing address:
  • Phone: 419-635-4462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number1573733
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: