Basic Information
| Provider Information | |||||||||
| NPI: | 1356087811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUGH | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | CHRISTINE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4420 S NIELSEN WAY | ||||||||
| Address2: | |||||||||
| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841195727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018155179 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH SALT LAKE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841153164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3856465000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2022 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 10631644-2402 | UT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.