Provider Demographics
NPI:1184653354
Name:PUGH, GAYLE A
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:A
Last Name:PUGH
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:PO BOX 2279
Mailing Address - Street 2:
Mailing Address - City:BUNA
Mailing Address - State:TX
Mailing Address - Zip Code:77612
Mailing Address - Country:US
Mailing Address - Phone:409-994-9323
Mailing Address - Fax:409-994-9290
Practice Address - Street 1:35607 HWY 96 SOUTH
Practice Address - Street 2:
Practice Address - City:BUNA
Practice Address - State:TX
Practice Address - Zip Code:77612
Practice Address - Country:US
Practice Address - Phone:409-994-9323
Practice Address - Fax:409-994-9290
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00890363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153391101Medicaid
TX8A3714Medicare PIN
TX153391101Medicaid
TX00726UMedicare PIN