Healthcare Provider Details

I. General information

NPI: 1164676177
Provider Name (Legal Business Name): SARAH Y PUCEK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 11/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 TUCKER ST SUITE 5
JACKSON TN
38301-4055
US

IV. Provider business mailing address

131 TUCKER ST SUITE 5
JACKSON TN
38301-4055
US

V. Phone/Fax

Practice location:
  • Phone: 931-388-6404
  • Fax:
Mailing address:
  • Phone: 931-388-6404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberAPN0000011444
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberRN0000084350
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: