Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251N0400X | Physical Therapist - Neurology | 9083705-2401 | UT |
NPI | 1578961041 |
---|---|
Provider Name | Dr. Evan Michael Pucillo |
First Address | Salt Lake City, UT 84102-1959 |
Second Address | Salt Lake City, UT 84132-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2014 |
Last Update Date | 22/09/2015 |