MEDICARE: JOEL PUNG RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT11721	FL

General Provider Information

NPI Number	:	1336419282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOEL PUNG RPT

Provider Business Mailing Address
First Line	:	2825 TERRA CEIA BAY BLVD
Second Line	:	# 1702
City	:	PALMETTO
State	:	FL
Zip	:	34221-5989
Country	:	US
Telephone Number	:	941-447-7274
Fax Number	:

Provider Business Practice Location Address
First Line	:	2825 TERRA CEIA BAY BLVD
Second Line	:	# 1702
City	:	PALMETTO
State	:	FL
Zip	:	34221-5989
Country	:	US
Telephone Number	:	941-447-7274
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2012
Last Update Date	:	04/28/2016

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