Provider Demographics
NPI:1346346210
Name:PUCKETT, MARY JANICE (PAC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANICE
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:PAC
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 2663
Mailing Address - Street 2:
Mailing Address - City:CULLOWHEE
Mailing Address - State:NC
Mailing Address - Zip Code:28723-2663
Mailing Address - Country:US
Mailing Address - Phone:828-293-3720
Mailing Address - Fax:
Practice Address - Street 1:538 SCOTTS CREEK RD, SUITE 100
Practice Address - Street 2:JCDPH
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779
Practice Address - Country:US
Practice Address - Phone:828-587-8267
Practice Address - Fax:828-587-8295
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S23430Medicare UPIN