Healthcare Provider Details

I. General information

NPI: 1164978581
Provider Name (Legal Business Name): KATHLEEN PUGH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W RIVER WOODS PKWY STE 130
GLENDALE WI
53212-1010
US

IV. Provider business mailing address

2500 N MAYFAIR RD STE 500
WAUWATOSA WI
53226-1415
US

V. Phone/Fax

Practice location:
  • Phone: 414-249-2420
  • Fax: 414-961-0298
Mailing address:
  • Phone: 414-257-2525
  • Fax: 414-443-1283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7281-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number180033-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: