Healthcare Provider Details

I. General information

NPI: 1477885994
Provider Name (Legal Business Name): ALTON RILEY PUGH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2010
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 S 200 W
BLANDING UT
84511
US

IV. Provider business mailing address

802 S 200 W
BLANDING UT
84511-3910
US

V. Phone/Fax

Practice location:
  • Phone: 435-678-3993
  • Fax: 435-678-3992
Mailing address:
  • Phone: 435-678-3993
  • Fax: 435-678-3992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCOA11321
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number5133328-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: