Provider Demographics
NPI:1710380233
Name:MRUGAL, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MRUGAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 SHOEMAKER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST WYOMING
Mailing Address - State:PA
Mailing Address - Zip Code:18644-1020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1425 SHOEMAKER AVE
Practice Address - Street 2:
Practice Address - City:WEST WYOMING
Practice Address - State:PA
Practice Address - Zip Code:18644-1020
Practice Address - Country:US
Practice Address - Phone:570-718-1996
Practice Address - Fax:570-718-1997
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN517454L364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult