Provider Demographics
NPI:1902867617
Name:PUGLISI, JACOB CHARLES (PA, ATC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:CHARLES
Last Name:PUGLISI
Suffix:
Gender:M
Credentials:PA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 24TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:VA
Mailing Address - Zip Code:23801-1716
Mailing Address - Country:US
Mailing Address - Phone:804-734-9226
Mailing Address - Fax:
Practice Address - Street 1:700 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:VA
Practice Address - Zip Code:23801-1716
Practice Address - Country:US
Practice Address - Phone:804-734-9226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260002852255A2300X
VA0110003638363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical