Provider Demographics
NPI:1992467377
Name:PUGACZEWSKI, GINA (PT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:PUGACZEWSKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:COREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7405 DAILEY LN
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-4507
Mailing Address - Country:US
Mailing Address - Phone:443-845-0137
Mailing Address - Fax:
Practice Address - Street 1:7405 DAILEY LN
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-4507
Practice Address - Country:US
Practice Address - Phone:443-845-0137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
P19664225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
30629242OtherLICENSE
014625289-01OtherTRICARE