Provider Demographics
NPI:1730775875
Name:PUCHALA, NATHANIEL JOSEPH (IDHS)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:JOSEPH
Last Name:PUCHALA
Suffix:
Gender:M
Credentials:IDHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ERIE INDUSTRIAL PARK BLDG 360
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-9412
Mailing Address - Country:US
Mailing Address - Phone:419-635-4462
Mailing Address - Fax:
Practice Address - Street 1:ERIE INDUSTRIAL PARK BLDG 360
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-9412
Practice Address - Country:US
Practice Address - Phone:419-635-4462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1573733146N00000X
CA247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic