Provider Demographics
NPI:1083369847
Name:PUGH-MARTIN, NICOLE ALEXANDRIA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALEXANDRIA
Last Name:PUGH-MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 W EDGAR RD # 1248
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-6574
Mailing Address - Country:US
Mailing Address - Phone:610-905-3752
Mailing Address - Fax:
Practice Address - Street 1:653 W EDGAR RD
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-6574
Practice Address - Country:US
Practice Address - Phone:610-905-3752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-19
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2020010822363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology