Healthcare Provider Details

I. General information

NPI: 1710380233
Provider Name (Legal Business Name): JOHN MRUGAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 SHOEMAKER AVE
WEST WYOMING PA
18644-1020
US

IV. Provider business mailing address

1425 SHOEMAKER AVE
WEST WYOMING PA
18644-1020
US

V. Phone/Fax

Practice location:
  • Phone: 570-718-1996
  • Fax: 570-718-1997
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberRN517454L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: