=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376984229
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL A PUGLISI PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2013
-----------------------------------------------------
Last Update Date | 11/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 MEMORIAL DR STE 1100
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54923-1243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-361-5535
-----------------------------------------------------
Fax | 920-361-6337
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 E COLLEGE AVE
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54911-5794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-996-3264
-----------------------------------------------------
Fax | 920-830-5910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 3428-23
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------