Provider Demographics
NPI:1073006375
Name:PUCHALA, GRZEGORZ SEBASTIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:GRZEGORZ
Middle Name:SEBASTIAN
Last Name:PUCHALA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82902-1359
Mailing Address - Country:US
Mailing Address - Phone:307-362-3711
Mailing Address - Fax:
Practice Address - Street 1:1200 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5868
Practice Address - Country:US
Practice Address - Phone:307-362-3711
Practice Address - Fax:307-352-8530
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS9053207R00000X
TXBP10062552390200000X
WYTL6832207R00000X
WY14038A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program