Provider Demographics
NPI:1760851182
Name:NUGPO, NERLAN (PT)
Entity Type:Individual
Prefix:
First Name:NERLAN
Middle Name:
Last Name:NUGPO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 JENNER AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-1607
Mailing Address - Country:US
Mailing Address - Phone:217-690-6588
Mailing Address - Fax:
Practice Address - Street 1:1115 N WENTHE DR
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1612
Practice Address - Country:US
Practice Address - Phone:217-347-7121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.021344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist