Provider Demographics
NPI:1114320652
Name:PUA, BERNADETTE (NP)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:PUA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1752 PRAIRE LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4577
Mailing Address - Country:US
Mailing Address - Phone:209-373-3907
Mailing Address - Fax:
Practice Address - Street 1:3031 W MARCH LN STE 123
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-6567
Practice Address - Country:US
Practice Address - Phone:209-476-8405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95019689363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily