Provider Demographics
NPI:1629007596
Name:PUPO, MARC ANTHONY (RN)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ANTHONY
Last Name:PUPO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2086
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-1918
Mailing Address - Country:US
Mailing Address - Phone:301-744-8553
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN107131163W00000X, 163WE0003X, 163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC81438OtherREGISTRATION NUMBER
CORN127602OtherREGISTRATION NUMBER
CA666998OtherREGISTRATION NUMBER
FLRN9219847OtherREGISTRATION NUMBER
AZRN109560OtherREGISTRATION NUMBER
MI4704237121OtherREGISTRATION NUMBER
GARN107131OtherREGISTRATION NUMBER