Provider Demographics
NPI:1174186340
Name:PUGH, ANGELA (A)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:PUGH
Suffix:
Gender:F
Credentials:A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12020 PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-3507
Mailing Address - Country:US
Mailing Address - Phone:804-869-4056
Mailing Address - Fax:
Practice Address - Street 1:12020 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-3507
Practice Address - Country:US
Practice Address - Phone:800-259-0287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604238208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2306604238OtherPTA LICENSE