Provider Demographics
NPI:1376952713
Name:PUGMIRE, JARED C (PT DPT)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:C
Last Name:PUGMIRE
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 W CHUBBUCK RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 W CHUBBUCK RD
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2933
Practice Address - Country:US
Practice Address - Phone:208-240-6017
Practice Address - Fax:208-240-6023
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5310208100000X
NV3018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist