Provider Demographics
NPI:1407961410
Name:PUCKETT, PAUL LAVAL (PAC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:LAVAL
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2464 FM 2820
Mailing Address - Street 2:
Mailing Address - City:SUMMER
Mailing Address - State:TX
Mailing Address - Zip Code:75486
Mailing Address - Country:US
Mailing Address - Phone:903-784-1291
Mailing Address - Fax:
Practice Address - Street 1:4215 JOE RAMSEY BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75403
Practice Address - Country:US
Practice Address - Phone:903-408-5000
Practice Address - Fax:214-712-2487
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P42485Medicare UPIN