Healthcare Provider Details

I. General information

NPI: 1376984229
Provider Name (Legal Business Name): MICHAEL A PUGLISI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 11/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MEMORIAL DR STE 1100
BERLIN WI
54923-1243
US

IV. Provider business mailing address

122 E COLLEGE AVE
APPLETON WI
54911-5794
US

V. Phone/Fax

Practice location:
  • Phone: 920-361-5535
  • Fax: 920-361-6337
Mailing address:
  • Phone: 920-996-3264
  • Fax: 920-830-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3428-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: