Provider Demographics
NPI:1578237459
Name:PUPO, LUNA
Entity Type:Individual
Prefix:
First Name:LUNA
Middle Name:
Last Name:PUPO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORDHAM HILL OVAL APT 12B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-8003
Mailing Address - Country:US
Mailing Address - Phone:646-420-6494
Mailing Address - Fax:
Practice Address - Street 1:1 FORDHAM HILL OVAL APT 12B
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-8003
Practice Address - Country:US
Practice Address - Phone:646-420-6494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21-454246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant