Provider Demographics
NPI:1831617455
Name:PUNGU, TSHA EDITH
Entity type:Individual
Prefix:
First Name:TSHA
Middle Name:EDITH
Last Name:PUNGU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5808 HUNTING RIDGE LANE APT A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212
Mailing Address - Country:US
Mailing Address - Phone:704-281-8806
Mailing Address - Fax:
Practice Address - Street 1:2905 FREEDOM DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208
Practice Address - Country:US
Practice Address - Phone:704-394-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-04
Last Update Date:2017-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF07171238363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily