Provider Demographics
NPI:1679019863
Name:PUIG, JOSHUA (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:PUIG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:757 WESTWOOD PLZ
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8358
Practice Address - Country:US
Practice Address - Phone:310-206-8232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11148363A00000X
IN10002663A363A00000X
CA59620363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA11148OtherTEXAS STATE MEDICAL BOARD