Provider Demographics
NPI:1649247362
Name:PUCELIK, PATRICK J (ARNP)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:PUCELIK
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 BLAIR ST
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:IA
Mailing Address - Zip Code:51063-1007
Mailing Address - Country:US
Mailing Address - Phone:712-455-2431
Mailing Address - Fax:712-455-2698
Practice Address - Street 1:153 BLAIR ST
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:IA
Practice Address - Zip Code:51063-1007
Practice Address - Country:US
Practice Address - Phone:712-455-2431
Practice Address - Fax:712-455-2698
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-106028363L00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
500018631OtherRAILROAD MEDICARE
500018631OtherRAILROAD MEDICARE
IAI7583Medicare ID - Type Unspecified