Healthcare Provider Details

I. General information

NPI: 1902867617
Provider Name (Legal Business Name): JACOB CHARLES PUGLISI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 24TH ST
FORT LEE VA
23801-1716
US

IV. Provider business mailing address

700 24TH ST
FORT LEE VA
23801-1716
US

V. Phone/Fax

Practice location:
  • Phone: 804-734-9226
  • Fax:
Mailing address:
  • Phone: 804-734-9226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003638
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110003638
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: