Provider Demographics
NPI:1477885994
Name:PUGH, ALTON RILEY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ALTON
Middle Name:RILEY
Last Name:PUGH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 S 200 W
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-3910
Mailing Address - Country:US
Mailing Address - Phone:435-678-3993
Mailing Address - Fax:435-678-3992
Practice Address - Street 1:802 S 200 W
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511
Practice Address - Country:US
Practice Address - Phone:435-678-3993
Practice Address - Fax:435-678-3992
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA11321367500000X
UT5133328-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered