Healthcare Provider Details

I. General information

NPI: 1942303250
Provider Name (Legal Business Name): KATHLEEN E PUCA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 N 18TH ST
MILWAUKEE WI
53233-2121
US

IV. Provider business mailing address

8085 RIVERS AVE STE 100
NORTH CHARLESTON SC
29406-9239
US

V. Phone/Fax

Practice location:
  • Phone: 414-937-6350
  • Fax:
Mailing address:
  • Phone: 843-569-8495
  • Fax: 770-237-4971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number44845020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: