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: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E MAIN ST
NORFOLK VA
23510-1753
US

IV. Provider business mailing address

300 E MAIN ST
NORFOLK VA
23510-1753
US

V. Phone/Fax

Practice location:
  • Phone: 757-840-9134
  • Fax:
Mailing address:
  • Phone: 757-840-9134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number1573733
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: