Provider Demographics
NPI:1578830253
Name:PUGACH, LEONID ALEX (PA)
Entity Type:Individual
Prefix:MR
First Name:LEONID
Middle Name:ALEX
Last Name:PUGACH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1055 DELLWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-1841
Mailing Address - Country:US
Mailing Address - Phone:510-724-4586
Mailing Address - Fax:
Practice Address - Street 1:2970 HILLTOP MALL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-1947
Practice Address - Country:US
Practice Address - Phone:510-724-4586
Practice Address - Fax:510-724-9247
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18605363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical