Provider Demographics
NPI:1346626876
Name:PUCKETT, THOMAS EDWIN JR (NP)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:EDWIN
Last Name:PUCKETT
Suffix:JR
Gender:M
Credentials:NP
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Mailing Address - Street 1:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:775-222-0044
Mailing Address - Fax:888-700-0187
Practice Address - Street 1:3834 S EMERSON AVE
Practice Address - Street 2:BLDG C STE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203
Practice Address - Country:US
Practice Address - Phone:317-782-1577
Practice Address - Fax:888-366-7577
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71005644A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201312180Medicaid
IN715320018Medicare PIN