Provider Demographics
NPI:1073539771
Name:PUKISH, NICHOLAS ALEXANDER JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ALEXANDER
Last Name:PUKISH
Suffix:JR
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:4440 FRUITVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-1926
Mailing Address - Country:US
Mailing Address - Phone:941-366-0134
Mailing Address - Fax:941-404-1760
Practice Address - Street 1:1825 HURLBURT RD STE 14
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-3737
Practice Address - Country:US
Practice Address - Phone:850-610-8820
Practice Address - Fax:844-297-8690
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2020-01-27
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Provider Licenses
StateLicense IDTaxonomies
FLPA 9100880363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical