Provider Demographics
NPI:1508993700
Name:PUGA, ERIC GILBERT (MS CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:GILBERT
Last Name:PUGA
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12637 S KOSH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-3340
Mailing Address - Country:US
Mailing Address - Phone:602-318-5470
Mailing Address - Fax:
Practice Address - Street 1:12637 S KOSH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-3340
Practice Address - Country:US
Practice Address - Phone:602-318-5470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP2056235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ797574Medicaid