Provider Demographics
NPI:1689626657
Name:PUPUMA, NOCOLLEGE A (PAC)
Entity Type:Individual
Prefix:MS
First Name:NOCOLLEGE
Middle Name:A
Last Name:PUPUMA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 RIVERSIDE PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5946
Mailing Address - Country:US
Mailing Address - Phone:770-513-0111
Mailing Address - Fax:770-513-3731
Practice Address - Street 1:1431 RIVERSIDE PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5946
Practice Address - Country:US
Practice Address - Phone:770-513-0111
Practice Address - Fax:770-513-3731
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003263363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical