Provider Demographics
NPI:1073539771
Name:PUKISH, NICHOLAS ALEXANDER JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ALEXANDER
Last Name:PUKISH
Suffix:JR
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:6255 W SUNSET BLVD FL 21
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7422
Mailing Address - Country:US
Mailing Address - Phone:323-860-5200
Mailing Address - Fax:323-467-7119
Practice Address - Street 1:189 WALMART LN STE B
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4564
Practice Address - Country:US
Practice Address - Phone:601-368-6254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2025-01-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA 9100880363AM0700X
MSPA00845363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical