Provider Demographics
NPI:1033224654
Name:NUGENT, JOHN W (PAC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:NUGENT
Suffix:
Gender:M
Credentials:PAC
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Mailing Address - Street 1:510 LINCOLN DRIVE
Mailing Address - Street 2:SOUTHERN ORTHOPEDIC ASSOCIATES SC
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948
Mailing Address - Country:US
Mailing Address - Phone:618-997-6800
Mailing Address - Fax:618-998-9124
Practice Address - Street 1:510 LINCOLN DRIVE
Practice Address - Street 2:SOUTHERN ORTHOPEDIC ASSOCIATES SC
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948
Practice Address - Country:US
Practice Address - Phone:618-997-6800
Practice Address - Fax:618-998-9124
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2011-02-07
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Provider Licenses
StateLicense IDTaxonomies
IL085001449363A00000X
IL085.001449207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881117Medicare PIN