Provider Demographics
NPI: | 1780661512 |
---|---|
Name: | PUITA, SHARON L (RN ANP-C) |
Entity Type: | Individual |
Prefix: | MS |
First Name: | SHARON |
Middle Name: | L |
Last Name: | PUITA |
Suffix: | |
Gender: | F |
Credentials: | RN ANP-C |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1428 PHILLIPS LN |
Mailing Address - Street 2: | 203 |
Mailing Address - City: | SAN LUIS OBISPO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 93401-2537 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 805-543-4407 |
Mailing Address - Fax: | 805-543-4587 |
Practice Address - Street 1: | 1428 PHILLIPS LN |
Practice Address - Street 2: | 203 |
Practice Address - City: | SAN LUIS OBISPO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 93401-2537 |
Practice Address - Country: | US |
Practice Address - Phone: | 805-543-4407 |
Practice Address - Fax: | 805-543-4587 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-12-22 |
Last Update Date: | 2014-04-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 456921 | 163W00000X |
CA | 14148 | 363L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | |
No | 163W00000X | Nursing Service Providers | Registered Nurse |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
Q48577 | Medicare UPIN | ||
WNP14148A | Medicare ID - Type Unspecified |