Provider Demographics
NPI:1760519912
Name:PUCCINELLI, SARAH GEMMA (PA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:GEMMA
Last Name:PUCCINELLI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:GIROLAMO
Other - Last Name:PUCCINELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 25487
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-2487
Mailing Address - Country:US
Mailing Address - Phone:941-202-5342
Mailing Address - Fax:855-253-4836
Practice Address - Street 1:3830 BEE RIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233
Practice Address - Country:US
Practice Address - Phone:941-927-5178
Practice Address - Fax:941-921-6838
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002542363A00000X
FLPA9111056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362960013Medicare PIN
WIWI3002004Medicare PIN
INM400065912Medicare PIN